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Some Asthma Sufferers May Not Need Daily Steroids

Those with mild cases might be able to use the drugs as needed, study finds

WEDNESDAY, April 13, 2005 (HealthDay News) -- Many people with mild persistent asthma use inhaled corticosteroids daily, hoping that by doing so they'll prevent additional inflammation and lung damage.

But a new study in the April 14 issue of the New England Journal of Medicine questions this long-held belief, and instead suggests that people with mild asthma may do just as well using inhaled corticosteroids only when their asthma flares.

"It may be possible to treat mild persistent asthma with short, intermittent courses of inhaled or oral corticosteroids taken when symptoms worsen," the study authors concluded.

Someone with mild persistent asthma has symptoms more than twice a week, but less than once a day, according to the American College of Allergy, Asthma & Immunology. Mild persistent asthma also causes nighttime symptoms more than twice a month, and you may sometimes have more severe episodes that limit your activity. More than 7 million Americans have mild persistent asthma, according to the National Heart, Lung, and Blood Institute.

Current treatment guidelines from the National Asthma Education and Prevention Program list daily inhaled corticosteroids as the preferred treatment method for those with mild persistent asthma. This recommendation came about because previous studies had suggested that daily inhaled corticosteroid use could reduce asthma symptoms and improve quality of life. But, more importantly, some studies suggested that daily steroid use might help prevent a decline in lung function, according to background information in the new study.

In practice, however, physicians found that many people with mild asthma weren't renewing their prescriptions for long-term controller medications, such as corticosteroid inhalers. The authors of the study suggest that one reason may be because symptoms are often mild, patients may not feel the need for daily medication.

To get a more scientific picture of what the best treatment for adults with mild persistent asthma might be, researchers from across the United States recruited 225 adults with mild persistent asthma to participate in a randomized, double-blind, placebo-controlled study. The study is called the Improving Asthma Control Trial (IMPACT).

For one year, one-third of the volunteers were given inhaled corticosteroids; one-third were instructed to take oral zafirlukast twice daily; the final third were given placebo medications.

Zafirlukast, sold under the brand name Accolate, is one of a new class of non-steroidal medications known as leukotriene receptor antagonists. These medications work by blocking the action of leukotrienes, a naturally occurring substance that in asthmatics can contribute to muscle tightening and airway inflammation. Like corticosteroids, leukotriene receptor antagonists are long-term controller medications, and shouldn't be used to treat an asthma attack.

Study volunteers were given a 10-minute education session, instructed to use a rescue medication (albuterol) if their symptoms worsened, and told to use either an inhaled corticosteroid for 10 days or an oral steroid for five days after the asthma exacerbation.

The researchers used common asthma assessment tools to follow the lung health of the study participants. They measured morning peak expiratory flow (PEF), forced expiratory volume (FEV) both before and after using an albuterol inhaler, the number of asthma flares, the number of symptom-free days and their reported quality of life.

At the end of the study, the researchers found little difference in lung function and quality-of-life scores between the three groups. Those taking daily inhaled corticosteroids did report about 26 more symptom-free days than the placebo or zafirlukast groups, but that difference didn't translate into a worsening quality of life for those groups.

"The results of IMPACT suggest that for some adults with longstanding mild persistent asthma, choosing not to take daily medications might be OK," one of the study's authors, Dr. Elliot Israel of Brigham and Women's Hospital in Boston, said in a statement.

This study "provides an interesting therapeutic option -- prompt treatment of mild exacerbations with inhaled steroids -- that is likely to provide benefits with low risk," said the author of an accompanying editorial, Dr. Leonardo Fabbri, a professor of respiratory medicine at the Universita degli Studi di Modena e Reggio Emilia-Policlinico di Modena in Modena, Italy.

"I think this study is helpful," said Dr. Jonathan Field, director of the allergy and asthma clinic at the New York University School of Medicine/Bellevue Medical Center in New York City. "This is something physicians always have a lot of questions about, and these findings can make us feel more comfortable using our clinical judgment with this patient population."

Field did express some concern, however, that people with mild persistent asthma need to be well-educated about symptoms to watch for and need to keep track of their peak flow readings.

Fabbri agreed and said the most important thing for patients is "to learn to recognize exacerbations of symptoms and to treat them promptly with a short course of inhaled steroids."

More information

To learn more about controlling asthma, visit the American College of Allergy, Asthma & Immunology.

SOURCES: Leonardo Fabbri, M.D., professor, respiratory medicine, Universita degli Studi di Modena e Reggio Emilia-Policlinico di Modena, Modena, Italy; Jonathan Field, M.D., director, allergy and asthma clinic, New York University School of Medicine/Bellvue Medical Center, New York City; April 14, 2005, New England Journal of Medicine
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