Experts recommend use of albuterol for mild asthma

Regularly scheduled therapy not indicated

Ending a five-year debate about the appropriate use of inhaled beta-agonists to treat mild asthma, researchers at the National Heart, Lung, and Blood Institute (NHLBI) in Bethesda, MD, are advocating that patients use albuterol as needed, rather than regularly.

"For the patient with only occasional asthma symptoms, there is no reason to take medication regularly," says Claude Lenfant, MD, director of the NHLBI.

Suzanne Hurd, PhD, director of the division of lung diseases at the NHLBI, says a recent study comparing regularly scheduled vs. as-needed albuterol for mild asthma indicates that peak expiratory airflow didn’t change significantly in patients on either regimen.1

She explains that for many years, most asthma experts have believed that prescribing albuterol — often referred to as a "beta-agonist" — on a regularly scheduled basis improved asthma symptoms. But studies done in the 1990s indicate that regular use of beta-agonists could create tolerance to the drug and actually increase asthma symptoms and even cause death, reports Hurd.2,3

"In our study, we made reference to the fact that physicians were very worried about how much beta-agonist should be used," she notes. "That’s why they did this study, to try to say that in patients with mild asthma, do we have to worry about [the disease becoming worse]? Some physicians feel if you start using beta-agonists, you have to use more and more of it. It becomes a vicious cycle."

Using more of drug may be harmful

Some patients use the beta-agonists and feel better, so they use more of the drug.

"That may be what led to some of these fatal asthma attacks — that people . . . just kept using more and more beta-agonists," Hurd says. "The controversy became how much beta-agonist can you allow and in what kind of patients."

The most recent study "closed the door on some of the controversy," she adds, because it indicated that in patients with mild asthma, beta-agonists used even on a regular basis didn’t cause any problems. (See related story about guidelines used to define mild asthma, at right.)

"In fact, [investigators] even showed that for those patients, you probably didn’t even need beta-agonists that much, and they still came out the same," says Hurd. "The bottom line is that physicians should feel comfortable using beta-agonists in these patients."

In the most recent study, investigators evaluated patients for six weeks. Patients were randomized to receive either albuterol, two puffs four times a day, or a placebo inhaler for 16 weeks. Patients in both groups were allowed to take additional albuterol as needed for the relief of asthma symptoms. During a final four-week withdrawal period, all patients received only as-needed albuterol.

The study indicated that even though average use of albuterol was five times higher in the regular-use group compared to the as-needed group, no significant differences were noted in terms of their lung function, asthma symptoms, or quality of life.

References

1. Drazen JM, Israel E, Boushey HA, et al. Comparison of regularly scheduled with as-needed use of albuterol in mild asthma. N Engl J Med 1996; 335:841-847.

2. Nelson HS, Szetler SJ, Martin RJ. Regular inhaled beta adrenergic agonists in the treatment of bronchial asthma: Beneficial or detrimental? Am Rev Respir Dis 1991; 44:249-250.

3. National Asthma Education Program. Executive summary: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health; 1994.