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Correspondence |

Rescue Treatment in Asthma FREE TO VIEW

Yves Bogaerts, MD; Rebecca De Pauw, MD
Author and Funding Information

From the Department of Pneumology, Sint-Jan General Hospital.

Correspondence to: Dr Rebecca De Pauw, AZ Sint-Jan Ruddershove 10, B-8000 Brugge, Belgium; e-mail: rebecca.depauw@azbrugge.be


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Bogaerts has been a shareholder in Pfizer, GlaxoSmithKline, and UCB. He also participated in clinical trials for Astra Zeneca in 2008. Dr De Pauw has no potential conflicts of interest to disclose with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(1):239-240. doi:10.1378/chest.09-1711
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To the Editor:

We read with great interest the clinical commentary in CHEST (June 2009) by Papi et al1 in which they propose an inhaled rapid-acting β2-agonist combined with a corticosteroid as standard reliever treatment in asthma. The science backing them is compelling. The authors then take a major leap by suggesting that maintenance treatment might be done away with, their own work already providing evidence in mild asthma.2

As the authors remark, this approach inevitably abandons “total control” as an end point. Indeed, asthma symptoms and their treatment become linked in a continuous feedback loop. For the patient, this implies a remaining burden of symptoms. Of course, one can argue that even with maintenance therapy, most people with asthma will remain symptomatic to some extent. In the Gaining Optimal Asthma ControL study, maybe the most ambitious of asthma studies, total control was achieved in approximately 40% of participants at best.3 But what to do with those punctual types among our patients, who are perfectly happy with a daily maintenance medication and the carefree respiration they may be rewarded with. Should we change them over to an as-needed regimen with, for them, intrinsically less result?

Problems may also arise when maintenance dosing is withheld from people with more severe asthma, who generally require more medication for satisfactory control. Their feedback loop will achieve its equilibrium not only at a higher medication dose but also, as an unintended backlash, with more residual asthma symptoms. To avoid this, the loop will have to be recalibrated as asthma becomes more severe (eg, by increasing the steroid dose taken at each occasion). So for severe asthma, maintaining a daily maintenance dose, or even increasing it, may be preferable. Hopefully, the upcoming Pan-European Eurosmart study (http://clinicaltrials.gov; identifier NCT00463866), which compares two dose levels of regular treatment with a budesonide/formoterol association, both with extra inhalations as needed, will provide more insight.

Another set of patients for whom a fixed maintenance dose may be necessary are the so-called “poor perceivers”: quite evidently, if they have to rely on what they feel, these patients may react too late.

In conclusion, we believe that treating asthma with a combined inhaler on a strictly as-needed basis will emerge as just one more option and that physicians will have to continue tailoring asthma treatment to their patients’ individual needs and characters.

Papi A, Caramori G, Adcock IM, Barnes PJ. Rescue treatment in asthma. More than as-needed bronchodilation. Chest. 2009;1356:1628-1633. [CrossRef] [PubMed]
 
Papi A, Canonica GW, Maestrelli P, et al. BEST Study Group Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med. 2007;35620:2040-2052. [CrossRef] [PubMed]
 
Bateman ED, Boushey HA, Bousquet J, et al. GOAL Investigators Group Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. Am J Respir Crit Care Med. 2004;1708:836-844. [CrossRef] [PubMed]
 

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References

Papi A, Caramori G, Adcock IM, Barnes PJ. Rescue treatment in asthma. More than as-needed bronchodilation. Chest. 2009;1356:1628-1633. [CrossRef] [PubMed]
 
Papi A, Canonica GW, Maestrelli P, et al. BEST Study Group Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med. 2007;35620:2040-2052. [CrossRef] [PubMed]
 
Bateman ED, Boushey HA, Bousquet J, et al. GOAL Investigators Group Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. Am J Respir Crit Care Med. 2004;1708:836-844. [CrossRef] [PubMed]
 
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