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Would high doses of an inhaled cortico-steroid be as effective as a short course of oral corticosteroids in the treatment of well-defined exacerbation of asthma? Levy and co-workers, in a double- blind, double-dummy study, gave 2 mg daily of inhaled fluticasone vs. a short reducing course of oral prednisolone, starting at 40 mg per day, using 413 total patients recruited from general practices in the United Kingdom. Treatment successes were defined as 10% or greater increase in percentage of best/predicted morning peak expiratory flow (PEF). Treatment failures were defined by PEF decrements, symptom-score worsening, or patient withdrawal. Although there was no significant difference in efficacy between the two groups, there was a 4.3% difference favoring oral prednisolone (probably not clinically meaningful) between the two groups.
Although the authors cite the British Thoracic Society guidelines on the management of acute asthma for their choice of daily prednisolone, other guidelines suggest higher doses of daily steroids, perhaps for a shorter period of time, to achieve a better effect.1,2 Rowe et al also found greater benefit with higher doses of prednisolone.3
The authors failed to monitor unwanted side effects from the two treatments. Although long-term side effects would be virtually impossible to assess, there might be substantial absorption from 2 mg of fluticasone, producing effects on the hypothalamic pituitary-adrenal axis.4-7
A subgroup of asthmatic subjects have steroid-phobia that translates into avoidance of oral corticosteroids. Such patients might favor the use of increasing doses of steroid aerosols, especially since many of them are on these agents in the first place. On the other hand, the cost of using large doses of fluticasone to manage an exacerbation, especially if this occurs frequently, would be considerably greater than the very inexpensive oral prednisolone or prednisone. It is also not known if a general increase in asthma medications other than steroid aerosols might accomplish the same goal. These could include an increase in, for example, oral antileu-kotrienes,8 nedocromil, or long-acting aerosolized beta agonists. A caveat must also be given against generalizing the results of this study. It would be a mistake for an inexperienced practitioner (or patient) to depend on an increase in steroid aerosol during a severe exacerbation instead of the use of oral steroids or an emergency room visit, especially in those situations that are not properly monitored for severity.
In conclusion, although this study compares oral steroids with steroid aerosol in a well-defined situation, it should only represent the first of many studies using different designs and different patient populations before our concept of managing moderate exacerbations of asthma with oral corticosteroids merits change.
1. National Heart, Lung, and Blood Institute. International consensus report on diagnosis and management of asthma. 1992.
2. National Heart, Lung, and Blood Institute. Global initiative for asthma. Pub #95-3659 1995.
3. Rowe BYH, et al. Effectiveness of steroid therapy in acute exacerbations of asthma: A meta-analysis. Am J Emerg Med 1992;10:301-310.
4. Ayers JG, et al. High-dose fluticasone propionate, 1 mg daily, vs. fluticasone propionate, 2 mg daily, or budesonide, 106 mg daily; in patients with chronic severe asthma. Eur Respir J 1993;8:579-586.
5. Boe J, et al. High-dose inhaled steroids in asthmatics: moderate efficacy gain and suppression of the hypothalamic- pituitary-adrenal (HPA) axis. Eur Respir J 1994;7:2179-2184.
6. Fabbri L, et al. Comparison of fluticasone propionate with beclomethasone propionate in moderate to severe asthma treated for one year. Thorax 1993;48:817-823.
7. Clark DJ, et al. Comparative adrenal suppression with inhaled budesonide and fluticasone propionate in adult asthmatic patients. Thorax 1996;51:262-266.
8. Spector SL. Leukotriene inhibitors and antagonists in asthma. Ann Allergy Asthma Immunol 1995;75: 563-570.