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Mild Asthmatics May Do Well With Less Medicine

Studies confirm step-down recommendations for those with controlled asthma

WEDNESDAY, May 16, 2007 (HealthDay News) -- People with well-controlled, mild asthma might have more treatment options than they, and possibly their doctors, thought.

A pair of studies in the May 17 issue of the New England Journal of Medicine compared the gold standard of treatment for mild, persistent asthma -- inhaled steroids twice a day, every day -- to combination medications that include inhaled corticosteroids and rescue medications known as beta agonists, or to the oral medication, montelukast (Singulair). In the end, there was scant difference between the different medications.

"These studies give us some room to step away from current guidelines, and show there are many effective ways to treat mild persistent asthma," said Dr. Jane Krasnick, chief of allergy at St. John Macomb Hospital in Warren, Mich.

Dr. Stephen Peters, lead author of one of the studies, said that while twice-a-day inhaled corticosteroids are probably still the best treatment choice, "there are alternatives that may be suitable to you" if you don't like using an inhaler twice a day or find it too hard to remember to take your medication twice a day.

"If you have good asthma control, you can think about stepping down your therapy," he added.

In Peters' study, the researchers recruited 500 people with mild, persistent asthma who already had their asthma symptoms well-controlled by taking 100 micrograms of inhaled fluticasone twice daily.

One hundred and sixty-nine people from this group were randomly assigned to continue taking fluticasone twice daily, while another 166 were assigned to take either 5 milligrams or 10 milligrams of montelukast once each night for 16 weeks. The final 165 people were asked to use the combination medication known as Advair once each night. Advair includes 100 micrograms of fluticasone and 50 micrograms of salmeterol, a long-acting beta agonist.

People in both the fluticasone and the fluticasone plus salmeterol group fared about the same, with both groups experiencing about a 20 percent treatment failure. About 30 percent of the montelukast group experienced a treatment failure. For the purposes of this study, Peters and his colleagues very broadly defined treatment failure to include a decline in lung function, the need for oral steroids or an urgent care visit due to asthma.

The number of symptom-free days was similar among all three groups, according to the study.

"If you look at the percent of days free of symptoms, people did well across the board," said Peters, a professor of pediatrics and pulmonary internal medicine at Wake Forest University Baptist Medical Center.

Some day, Peters said, the hope is that doctors will be able to look at your genes and know which asthma medication will work best for you.

The second study, done by Italian researchers, compared 455 people with mild asthma randomly selected for one of four groups: one group used a combination medication that included 250 micrograms of inhaled beclomethasone -- another corticosteroid -- and 100 micrograms of albuterol, a short-acting beta agonist, plus a placebo inhalation medication twice daily (as-needed combination therapy); another group used a placebo twice daily, plus 100 micrograms of albuterol as needed (as-needed albuterol therapy); the third group 250 micrograms of beclomethasone twice a day and the use of 100 micrograms albuterol as needed (regular beclomethasone therapy). The final group was the use of a combination inhaler twice a day, plus albuterol as needed (regular combination therapy).

The lung function for those on as-needed combination therapy were slightly higher than those on as-needed albuterol therapy, but the as-needed combination therapy didn't differ much from those receiving regular beclomethasone. This is important, because the as-needed combination group received a lower dose of beclomethasone overall.

And, while inhaled corticosteroids are safe medications with few side effects, a lower dose of medicine would likely be even safer, and Krasnick pointed out that the cost would be lower.

"There may be some patients who can take medications on an as-needed basis, but you have to make sure you know what to do if you start to get into trouble," advised Krasnick.

Peters said, "If you're doing well on twice a day therapy, and you don't mind taking the medication, stick with it. This is still the best option for most. If you have allergic rhinitis, as well as asthma, montelukast is approved for that, and that might be a good reason to try it."

He added that people who don't like using medication twice a day might want to ask their doctor if Advair is a good option for them.

Peters' study was funded by an unrestricted grant from GlaxoSmithKline -- an asthma medication manufacturer -- and a grant from the American Lung Association. The Italian study received support from Chiesi Pharmaceuticals, also an asthma medication manufacturer.

More information

To learn more about stepping down your asthma medications, visit the American Academy of Allergy, Asthma and Immunology.

SOURCES: Stephen Peters, M.D., professor, pediatrics and pulmonary internal medicine, and associate director, Center for Human Genomics, Wake Forest University Baptist Medical Center, Winston-Salem, N.C.; Jane Krasnick, M.D., chief, allergy, St. John Macomb Hospital, Warren, Mich.; May 17, 2007, New England Journal of Medicine
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