0
Correspondence |

Response FREE TO VIEW

Alberto Papi, MD; Gaetano Caramori, MD, PhD; Ian M. Adock, PhD; Peter J. Barnes, DM, FCCP
Author and Funding Information

From the Centro di Ricerca su Asma e BPCO (Drs Papi and Caramori), Università di Ferrara; and the National Heart and Lung Institute (Drs Adock and Barnes), Imperial College London.

Correspondence to: Alberto Papi, MD, Centro di Ricerca su Asma e BPCO, Università di Ferrara, Via Savonarola 9, 44121 Ferrara, Italy; e-mail: ppa@unife.it


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Papi received research funding from and has been on Scientific Advisory Boards for AstraZeneca, Chiesi, GlaxoSmithKline, and UCB. Dr Caramori has received lecture fees from GlaxoSmithKline and Chiesi Farmaceutici. Dr. Adcock received research funding from and has been on Scientific Advisory Boards for GlaxoSmithKline, Chiesi, and AstraZeneca. Dr Barnes received research funding from and has been on Scientific Advisory Boards for AstraZeneca, Chiesi, Cipla, GlaxoSmithKline, and UCB.

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):240-241. doi:10.1378/chest.09-1863
Text Size: A A A
Published online

To the Editor:

We thank Drs Bogaerts and de Pauw for their insightful comments on our Clinical Commentary recently published in CHEST (June 2009).1 Although they support our proposal to move from rapid-acting inhaled β2-agonists alone to a corticosteroid (ICS) with a rapid-acting β2-agonist combination inhaler as standard reliever treatment in asthma, they raise concerns about the more provocative proposal on the use of combination inhalers on a strictly as-needed basis without regular maintenance treatment.

By way of clarity, we wish to emphasize that our Commentary was focused on the emerging clinical and pharmacological evidence that rescue combination inhalers are more effective than currently recommended short-acting β2-agonists for all degrees of asthma severity. At the end of our Commentary we speculated that in the future it might be even possible to show that the use of a rescue combination inhaler alone is sufficient to control asthma. Although we agree with some of the concerns raised by Drs Bogaerts and de Pauw, still we believe that the option of using the combination as rescue alone without regular maintenance therapy at least needs to be tested in controlled trials. In an era in which we desire to personalize medicine, some patients with asthma might accept a certain degree of symptoms,2 while adjusting the amount of treatment in response to symptoms, and forgo the total symptom control that is currently attainable (even with the most stringent step-up approach) only in around 40% of patients.3 Patients with more severe asthma would take more inhaled steroid along with bronchodilators, whereas taking a β2-agonist alone would not improve their control. In the real world, the same group of patients is likely to take little maintenance inhaled corticosteroid and thus will not be well controlled.

Some evidence backing our proposal is already available for mild asthma.4,5 Whether an as-needed-only approach is also appropriate for patients with more severe asthma is still under investigation. From a pathogenetic perspective, a recent study showed that lower airways eosinophilic inflammation is well controlled using low doses of ICS with no obvious difference in clinical control between low and high doses of ICS.6

With these premises, we do not suggest to initiate an as-needed-only regimen in all patients with asthma. For those who achieve asthma control and are happy with regular maintenance treatment there may be no need to modify their treatment regimen, although an as-needed-only strategy can still represent a step-down option for well-controlled patients.7 Obviously, the use of an as-needed-only strategy is not a recommended option for the clinical phenotype of the poor-perceiver patient with asthma, who may need objective monitoring with peak expiratory flow measurements.

We agree with the conclusion that, if the ongoing studies will confirm its efficacy, the as-needed-only strategy will became an appealing therapeutic option for tailoring asthma treatment to patients’ needs.

Papi A, Caramori G, Adcock IM, Barnes PJ. Rescue treatment in asthma. More than as-needed bronchodilation. Chest. 2009;1356:1628-1633. [CrossRef] [PubMed]
 
Partridge MR, van der Molen T, Myrseth SE, Busse WW. Attitudes and actions of asthma patients on regular maintenance therapy: the INSPIRE study. BMC Pulm Med. 2006;6:13-21. [CrossRef]
 
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]
 
Boushey HA, Sorkness CA, King TS, et al. National Heart, Lung, and Blood Institute’s Asthma Clinical Research Network Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med. 2005;35215:1519-1528. [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]
 
Pavord ID, Jeffery PK, Qiu Y, et al. Airway inflammation in patients with asthma with high-fixed or low-fixed plus as-needed budesonide/formoterol. J Allergy Clin Immunol. 2009;1235:1083-1089. [CrossRef] [PubMed]
 
Bateman ED, Hurd SS, Barnes PJ, et al. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J. 2008;311:143-178. [CrossRef] [PubMed]
 

Figures

Tables

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]
 
Partridge MR, van der Molen T, Myrseth SE, Busse WW. Attitudes and actions of asthma patients on regular maintenance therapy: the INSPIRE study. BMC Pulm Med. 2006;6:13-21. [CrossRef]
 
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]
 
Boushey HA, Sorkness CA, King TS, et al. National Heart, Lung, and Blood Institute’s Asthma Clinical Research Network Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med. 2005;35215:1519-1528. [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]
 
Pavord ID, Jeffery PK, Qiu Y, et al. Airway inflammation in patients with asthma with high-fixed or low-fixed plus as-needed budesonide/formoterol. J Allergy Clin Immunol. 2009;1235:1083-1089. [CrossRef] [PubMed]
 
Bateman ED, Hurd SS, Barnes PJ, et al. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J. 2008;311:143-178. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543