Asthma is a common disease and acute exacerbation can result in hospitalization and sometimes death. Doubling the inhaled glucocorticoid dose when asthma control deteriorates is no more effective in preventing an acute exacerbation than continuing the same dose. Therefore the authors randomized patients age 16 and older with a diagnosis of asthma who were using inhaled glucocorticoids to either quadruple the dose of their inhaled glucocorticoid or not increase the dose when asthma control deteriorated. Patients were trained by the study team to monitor their symptoms, reliever inhaler use and peak flow and modify inhaled glucocorticoid dose based on these parameters.
The primary outcome was time to first severe exacerbation, defined as requiring systemic glucocorticoids or an emergency visit for asthma management. Of the 1992 study subjects, 1114 (58%) had deterioration in their asthma control. Severe asthma exacerbation in the year after randomization occurred in 420 (45%) in the quadrupling group, compared to 484 (52%) in the non-quadrupling group, with an adjusted hazard ratio for the time to a first exacerbation of 0.81 (95% confidence interval [CI], 0.71 to 0.92; P=0.002), or a 19% reduction in asthma exacerbation.
While the difference is statistically significant, whether this is a clinically meaningful is less clear. The authors pre-specified a difference of 30% as clinically important, and, as pointed out in the accompanying editorial, quadrupling the dose dose not prevent most asthma exacerbations. Additionally, while there was no difference in pneumonia between the groups, oral candidiasis was more common in the quadrupling group. At this time, self management with quadrupuled dose of inhaled glucocorticoid should not be considered standard management for asthma control deterioration.
Additional information about Budesonide and Fluticasone can be found in the Top 300 Pharmacy Drug Cards. If you or your institution subscribes to AccessPharmacy, use or create your MyAccess Profile to sign-in to the Top 300 Pharmacy Drug Cards. If your institution does not provide access, ask your medical librarian about subscribing.
Read more at: McKeever T, Mortimer K, Wilson A, Walker S, Brightling C, Skeggs A, Pavord I, Price D, Duley L, Thomas M, Bradshaw L, Higgins B, Haydock R, Mitchell E, Devereux G, Harrison T. Quadrupling Inhaled Glucocorticoid Dose to Abort Asthma Exacerbations. N Engl J Med. 2018 Mar 8;378(10):902-910.
Bardin PG. Escalating Inhaled Glucocorticoids to Prevent Asthma Exacerbations. N Engl J Med. 2018 Mar 8;378(10):950-952.