PURPOSE: To systematically review the clinical effectiveness of increasing the dose of inhaled corticosteroid (ICS) compared to maintaining the usual maintenance dose during asthma exacerbations as part of a patient-initiated action plan.
METHODS: We searched the Cochrane Airways Group Specialized Register, as well as handsearched respiratory journals and meeting abstracts. Randomised controlled trials were included if they compared increased daily dose of ICS to continuation of stable maintenance dose early in the home management of an asthma exacerbation. The primary outcome was treatment failure defined as the need for rescue oral corticosteroids.
RESULTS: Five RCTs involving a total of 1098 patients with mild to moderate asthma were included. For the primary outcome, there was no significant reduction in the need for rescue oral corticosteroids when patients were randomised to increased ICS compared to stable maintenance dose, after pooling 3 parallel studies representing 1080 patients (OR 0.87, 95% CI 0.55 to 1.36, ITT analysis). There was no significant increase in the overall risk of reported non-serious adverse events associated with the increased ICS dose strategy (N=2; OR 2.15, 95% CI 0.68 to 6.73) and there were no serious adverse events reported. There was insufficient data to allow pooling of results on other secondary outcomes.
CONCLUSION: In patients with asthma on daily maintenance ICS, a self-initiated ICS increase to 1000-2000 mcg/day at the onset of an exacerbation is not associated with a statistically significant reduction in the risk of exacerbations requiring rescue oral corticosteroids. The increased ICS dose strategy was not associated with a higher risk of overall side effects.
CLINICAL IMPLICATIONS: There is no evidence at present to support the strategy of increasing the dose of ICS at the onset of an asthma exacerbation as part of a patient-initiated action plan to reduce the need for rescue systemic corticosteroids. Further studies are required to determine if ICS dose step-up in excess of doubling is beneficial.
DISCLOSURE: Bradley Quon, Grant monies (from industry related sources) Francine Ducharme has received grant support for investigator-initiated studies from Merck and Co and GlaxoSmithKline. Mark Fitzgerald has carried out a number of clinical research projects funded by industry related to optimal asthma management including one specifically addressing the issue under review. Catherine Lemière has received grant support for investigator initiated study from Merck-Frosst and GlaxoSmithKline.; Consultant fee, speaker bureau, advisory committee, etc. Mark Fitzgerald has worked as a consultant for a number of companies presenting at CME events and also in an advisory capacity re clinical research programs.Catherine Lemière has worked as a consultant for a number of companies (Topigen and GlaxoSmithKline). She has been a member of advisory boards for AstraZeneca, Altana and GlaxoSmithKline.; No Product/Research Disclosure Information