Basing treatment on symptoms could reduce the amount of drug used, minimize the risk of side effects, and may save billions of dollars in health care costs every year, researchers say.
Guidelines advise that people with mild to moderate asthma use inhaled corticosteroids twice a day to control their asthma. In addition, patients are supposed to use fast-acting “rescue” medications, such as albuterol, when needed to open up their airways and relieve symptoms.
Under the guidelines, “I think we’ve managed a lot of patients very well,” says Norman Edelman, MD, chief medical officer of the American Lung Association. He was not involved in the study.
But getting people to use inhaled corticosteroids every day when they feel fine “is a huge issue,” Edelman says. “Patients tend to take medicine until they feel as good as they’re going to feel.”
The study appears in this week’s Journal of the American Medical Association.
Birth of an Idea
Patients’ frequent skipping of inhaled corticosteroids led to the idea that tying the drugs’ use to that of the rescue medications might lead to better asthma control for those with relatively mild disease, George O’Connor, MD, and Joan Reibman, MD, write in an editorial accompanying the study.
To test that, researchers assigned 342 adults to one of three treatment groups. All of the study participants had mild to moderate asthma that was controlled by inhaled steroids.
For one group, a doctor following National Asthma Education and Prevention Program guidelines prescribed twice-daily inhaled steroids, adjusting the dose if deemed necessary at visits every six weeks.
In the second group, doctors adjusted patients’ twice-daily dose of steroids based on a check every six weeks of how much nitric oxide they exhaled. When airways are inflamed, the lungs produce higher levels of nitric oxide, so measuring how much of the gas is exhaled is used to help monitor the effectiveness of asthma medications.
In the third group, patients took two puffs of a steroid every time they took two puffs of albuterol to relieve asthma symptoms.
Less Medication Used
The nine-month study, sponsored by the National Heart, Lung, and Blood Institute, found that patients who inhaled a steroid only when they had asthma symptoms were no more likely to experience a worsening of their disease than those treated according to guidelines. In addition, the patients who inhaled a corticosteroid only when needed ended up using half as much drug as the others in the study.
“This strategy empowers patients to take control of their asthma,” says William Calhoun, MD, a lung disease specialist at the University of Texas Medical Branch in Galveston and a researcher on the study.
“We have some confidence that they will not do worse, and in some cases (they will) do better” than those who use inhaled corticosteroids twice a day, Calhoun says. A handful of other studies have also found the symptom-based approach to be effective, he says.
In their editorial, though, O’Connor and Reibman write that larger studies are needed before the guidelines are changed to recommend that patients with mild to moderate disease use inhaled corticosteroids only when they have symptoms. Basing patients’ dose adjustments on exhaled nitric oxide levels hasn’t been shown to be effective, they write, so “there is no compelling rationale to alter the current approach to [inhaled corticosteroid] dosing.”
For primary care doctors, following the guidelines and prescribing twice-daily use of inhaled corticosteroids “is [worthy], and it’s exactly the right thing to do,” Calhoun says. But, he says, he has offered some patients the symptom-based approach, which is probably best left up to asthma specialists.
One concern is that patients with more serious asthma will try the symptom-based approach to inhaled corticosteroids, says Homer Boushey, MD, a longtime asthma researcher at the University of California, San Francisco, who worked on the study.
“People underestimate the severity of their disease,” Boushey says, noting that lung function was carefully monitored in all of the patients in his study from beginning to end. “This is really only for people with truly mild disease” and under a doctor’s care.