Simpler asthma treatment options found effective

Some people with mild asthma using a twice-daily inhaled steroid to prevent asthma symptoms might be able to cut their medication use to only once a day, according to a study by the American Lung Association (ALA).

“This finding could allow some patients to simplify their treatment,” says Mario Castro, M.D., M.P.H., associate professor of medicine and pediatrics in the Division of Pulmonary and Critical Care Medicine at Washington University School of Medicine in St. Louis. “That would not only reduce the cost of their medications, but also lessen the possible side effects of corticosteroid use.”

Inhaled steroids at the dose most asthmatics take actually are associated with few, relatively mild side effects, according to Castro. These can include throat irritation, dry mouth or cough. But long-term use of high-dose inhaled corticosteroids can increase the risk of cataracts and glaucoma, suppress adrenal gland function or lead to osteoporosis. “Parents sometimes have a fear of giving their children steroids,” Castro says. “So another benefit of decreasing medications for mild asthma is that it would reassure parents that their child is getting the best treatment at the lowest dose possible.”

The study, published in the May 17 issue of the New England Journal of Medicine, was conducted by the ALA Asthma Clinical Research Centers, a network of 20 centers in the United States. Castro heads the center at Washington University.

The research centers enrolled 500 people with mild asthma who use daily maintenance, or controller, medication. Such patients experience asthma symptoms less than once per day, and their symptoms are limited to episodes of wheezing that normally respond to quick-relief bronchodilators.

Prior to the study, all of the participants routinely inhaled a standard dose of fluticasone (Flovent®) twice a day. The study volunteers’ average age was 31, but 79 were children, aged six to 18. Sixty percent of the volunteers were female, and 35 percent were black or Hispanic.

Researchers randomly assigned participants to one of three study groups: one group – the comparison group – stayed on their original treatment, and the other two groups were switched to once-daily medications. Neither patients nor physicians knew which medication was assigned to individual patients.

The researchers measured how long the medications prevented an asthma attack, a drop in lung function, the need to repeatedly use a fast-acting bronchodilator or an unexpected visit to the doctor or emergency room — these events were considered treatment failures.

One “once-a-day” group did just as well as the comparison group. These patients took once-daily inhaled fluticasone plus salmeterol (Advair 100®). Salmeterol is a long-acting drug that dilates the lung’s airways. Only 20 percent of these patients experienced treatment failure during the 16-week study – the same as the comparison group.

The second “once-a-day” group fared slightly worse than the comparison group. They used once-daily montelukast (Singulair®), a non-steroid anti-inflammatory drug taken in pill form. Thirty percent of these participants experienced treatment failure.

“These results could definitely impact what physicians recommend for their patients,” says Castro, a pulmonary specialist at Barnes-Jewish Hospital. “And I think the potential to go to a once-daily treatment will be especially welcome news for people with children – parents sometimes struggle to get their children to use the inhaler appropriately and to take their asthma medication twice a day.”

Castro stresses the seriousness of even mild asthma, which kills about 4,500 people each year in the United States. “I’d like to alert the public to the importance of recognizing symptoms of asthma,” he says. “If you have a tightness in the chest, shortness of breath or wheezing or persistent cough – especially at night, you should talk to your doctor and get tested for asthma.”

Members of the Writing Committee of the American Lung Association Asthma Clinical Research Centers. Randomized comparison of strategies for reducing treatment in mild persistent asthma. New England Journal of Medicine, May 17, 2007.

The study was partially supported by GlaxoSmith-Kline and the American Lung Association. Asthma Clinical Research Centers also receive funding from a variety of other sources.

Washington University School of Medicine’s full-time and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked fourth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.