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Communications to the Editor |

What About Add-On Second-Line Controller Therapy? FREE TO VIEW

Graeme P. Currie, MD; Sudip Saha, MBChB
Author and Funding Information

Affiliations: Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom,  Raigmore Hospital, Inverness, Scotland, United Kingdom,  University Hospital Aintree, Liverpool, UK

Correspondence to: Graeme P. Currie, MD, Department of Respiratory Medicine, Chest Clinic C, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, Scotland, UK; e-mail: graeme_currie@yahoo.com



Chest. 2005;127(3):1077-1078. doi:10.1378/chest.127.3.1077
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Published online

To the Editor:

The review by Roland et al (July 2004)1in CHEST has provided a timely reminder of the local adverse consequences of the use of inhaled corticosteroids in treating asthma. However, while playing an integral role in the management of inflammatory airways disease, inhaled corticosteroids are effective when used in smaller doses in combination with additional second-line controller therapy.2 This is especially pertinent, and indeed is advised, in patients with mild-to-moderate disease whose conditions are suboptimally controlled with low-dose inhaled corticosteroids.3

In their article, the authors do not mention the use of concomitant nonsteroidal antiinflammatory therapy with leukotriene receptor antagonists or long-acting β2-agonists. Using these agents would obviously permit a lower inhaled corticosteroid dose to be used, while maintaining or even improving asthma control.3 In turn, this would reduce the dose of corticosteroid delivered to both the oropharynx and endobronchial tree, minimizing the risk of both troublesome local and serious systemic sequelae. Common sense tells us that we should continue to advise patients to use a spacer device, rinse their mouths, and gargle after using an inhaled corticosteroid. Moreover, clinicians should be aware that the addition of second-line controller therapy with a concomitant reduction of inhaled corticosteroid dose should be considered when dealing with a patient with oropharyngeal candidiasis and dysphonia. Indeed, encountering an asthmatic patient with such problems provides an ideal opportunity to consider adjusting the burden of inhaled antiinflammatory therapy.

Roland, NJ, Bhalla, RK, Earis, J (2004) The local side effects of inhaled corticosteroids: current understanding and review of the literature.Chest126,213-219. [CrossRef] [PubMed]
 
Bjermer, L, Bisgaard, H, Bousquet, J, et al Montelukast and fluticasone compared with salmeterol and fluticasone in protecting against asthma exacerbation in adults: one year, double blind, randomised, comparative trial. BMJ. 2003;;327 ,.:891. [CrossRef] [PubMed]
 
British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma.Thorax2003;58(suppl),i1-i94
 
Shrewsbury, S, Pyke, S, Britton, M Meta-analysis of increased dose of inhaled steroid or addition of salmeterol in symptomatic asthma (MIASMA).BMJ2000;320,1368-1373. [CrossRef] [PubMed]
 
To the Editor:

We read the letter from Dr. Currie with interest, and we agree with the issues raised in the letter.

Our article was primarily written to bring to everyone’s attention the side effects of corticosteroids in the upper airway. We think that these quite distressing symptoms are often ignored.

The basic thrust of the article was to describe the side effects and to discuss what can be done for those patients who need therapy with inhaled steroids to control their symptoms. The assumption was that there are a large number of patients who are receiving full asthma treatment according to the guidelines, including long-acting β2-antagonists and leukotreine antagonists, who still require large doses of inhaled steroids.

We fully accept that all patients would be treated according to the various guidelines, which clearly state that long-acting β-blockers are an integral part of asthma management when the dose of inhaled steroids is getting above 800 μg/d (British Thorac Society guidelines). The latest British Thorac Society guidelines also have introduced add-on therapy at an earlier stage on the basic assumption that this provides better control and will have some steroid-sparing effect. In addition, there is now increasing evidence that doubling the dose of inhaled corticosteroids during an exacerbation is probably not very effective.

Leukotreine antagonists do seem to have some steroid-sparing effect for inhaled steroids (the effect for oral steroids is much more controversial). However, there is still considerable debate about the stage at which they should be used.

Thus, we agree with Dr. Currie that everything possible should be done to provide good asthma control, including the case of add-on therapies. However, even when all this is done, many patients will still be complaining of upper airway side effects resulting from their use of inhaled corticosteroids.


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References

Roland, NJ, Bhalla, RK, Earis, J (2004) The local side effects of inhaled corticosteroids: current understanding and review of the literature.Chest126,213-219. [CrossRef] [PubMed]
 
Bjermer, L, Bisgaard, H, Bousquet, J, et al Montelukast and fluticasone compared with salmeterol and fluticasone in protecting against asthma exacerbation in adults: one year, double blind, randomised, comparative trial. BMJ. 2003;;327 ,.:891. [CrossRef] [PubMed]
 
British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma.Thorax2003;58(suppl),i1-i94
 
Shrewsbury, S, Pyke, S, Britton, M Meta-analysis of increased dose of inhaled steroid or addition of salmeterol in symptomatic asthma (MIASMA).BMJ2000;320,1368-1373. [CrossRef] [PubMed]
 
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