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Do Patients with Mild Asthma Need Daily Inhaled Steroids?

Maybe not. Intermittent steroid use to treat worsening symptoms might be enough.

According to national guidelines, mild persistent asthma is defined by a need for ß-agonist treatment more than 2 days per week (but less than daily), asthma-related nighttime awakenings more than twice per month (but not more than once weekly), or spirometric criteria (http://www.nhlbi.nih.gov/health/prof/lung/asthma/practgde/practgde.pdf). Daily inhaled corticosteroids are recommended for such patients, but is such treatment really necessary?

In this partially industry-supported, multicenter trial, 225 adults with mild persistent asthma were randomized to receive twice-daily inhaled budesonide plus placebo tablets, twice-daily oral zafirlukast plus placebo inhaler, or twice-daily double placebo. Patients used inhaled albuterol as needed; in addition, all were instructed in self-treatment with a 10-day course of inhaled high-dose budesonide or a 5-day course of oral prednisone for worsening symptoms.

After 1 year, the groups did not differ significantly in the primary outcome (change from baseline in morning peak expiratory flow) or in the number of asthma exacerbations warranting prednisone treatment. Patients in the twice-daily budesonide group had significantly more symptom-free days per 2-week period than patients in the other two groups (mean, 10 vs. 9 vs. 9 days), but quality-of-life scores were similar in all groups.

Comment: This trial suggests that adults with mild persistent asthma do not necessarily need daily preventive treatment. Patients in the double-placebo group (who received only intermittent therapy to treat worsening symptoms) did nearly as well as those who received daily inhaled steroid, and just as well as those who received daily zafirlukast. The authors believe, however, that longer and larger studies should be done before guidelines are changed.

— Allan S. Brett, MD

Published in Journal Watch General Medicine April 22, 2005

Citation(s):

Boushey HA et al. Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med 2005 Apr 14; 352:1519-28.

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