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High-Dose Inhaled Corticosteroid Versus Long-Acting β-Agonist Addition in Asthma FREE TO VIEW

Mike Thomas, MB, BS; David Prince, MB, BS
Author and Funding Information

University of Aberdeen Aberdeen, UK

Correspondence to: Mike Thomas, MB, BS, Asthma UK Senior Research Fellow, Centre of Academic Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Rd, Aberdeen AB25 2AY, UK; e-mail: mikethomas@doctors.org.uk


The authors have reported to the ACCP that no significant conflicts of interest exist 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).


© 2009 American College of Chest Physicians


Chest. 2009;135(5):1404-1405. doi:10.1378/chest.08-2947
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To the Editor:

We read with interest the recent article in CHEST (December 2008) by O'Byrne et al1 presenting a post hoc analysis of the FACET database, which concluded that the addition of a long-acting β-agonist (LABA) increases the probability of well-controlled asthma compared to an increase in inhaled corticosteroid (ICS) dose. Asthma control is a complex and multifaceted concept,2 and disconnects have been reported3 between “day-to-day” symptom control and exacerbation frequency. We believe there is value in further examining this disconnect.

In the current analysis, although an increase in ICS dose was unlikely to result in improvements in sustained symptom control, the exacerbation frequency (defined as the need for courses of oral corticosteroids) was considerably to be lower in the high-dose ICS group (0.36 courses per year) than in the low-dose group (0.72 courses per year), and the proportions of patients having one or more exacerbations per year was also lower in the high-dose ICS group (22% vs 32%, respectively). Interestingly, the exacerbation frequency was also lower in the high-dose ICS group (0.36 courses per year) than in the low-dose-ICS-plus-LABA group (0.48 courses per year), implying that a subgroup of patients may gain greater benefit from an increase in ICS dose than from the addition of a LABA. Although exacerbations are infrequent in most patients with mild-to-moderate asthma, they are the time when the patient has the most risk, distress, and health resource use, so reducing the exacerbation risk may be important for exacerbation-prone patients.

We have recently reported4 similar findings in an observational study comparing clinical outcomes in cohorts of asthmatic patients whose routine therapy was increased from the standard dose of an ICS by either increasing the ICS dose or by the addition of a LABA; we found that although LABA addition was associated with better odds for successful overall control using a composite measure, high-dose ICS treatment was associated with lower odds of requiring oral corticosteroid therapy (odds ratio, 0.75; 95% confidence interval, 0.71 to 0.78). We concluded that although symptomatic control and rescue bronchodilator use may be improved by the addition of a LABA to ICS therapy, there may be a lower risk of severe exacerbations from the ICS dose increase; we feel the data reported by O'Byrne and colleagues1 are consistent with this.

The implication of this finding, which is not discussed in the article by O'Byrne et al,1 is that patients with more frequent exacerbations are likely to have persisting airways inflammation, and so are likely to benefit from improved antiinflammatory control, while those with ongoing symptoms are more likely to benefit from the addition of a LABA. Further research on the phenotyping and segmentation of patients to guide therapy decisions is needed.

O'Byrne PM, Naya IP, Kallen A, et al. Increasing doses of inhaled corticosteroids compared to adding long-acting inhaled β2-agonists in achieving asthma control. Chest. 2008;134:1192-1199. [PubMed] [CrossRef]
 
Taylor DR, Bateman ED, Boulet LP, et al. A new perspective on concepts of asthma severity and control. Eur Respir J. 2008;32:545-554. [PubMed]
 
Gibson PG, Powell H, Ducharme F. Differential effects of maintenance long-acting β-agonist and inhaled corticosteroid on asthma control and asthma exacerbations. J Allergy Clin Immunol. 2007;119:344-350. [PubMed]
 
Thomas M, von Ziegenweidt J, Lee AJ, et al. High-dose inhaled corticosteroids versus add-on long-acting β-agonists in asthma: an observational study. J Allergy Clin Immunol. 2009;123:122-123. [PubMed]
 

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References

O'Byrne PM, Naya IP, Kallen A, et al. Increasing doses of inhaled corticosteroids compared to adding long-acting inhaled β2-agonists in achieving asthma control. Chest. 2008;134:1192-1199. [PubMed] [CrossRef]
 
Taylor DR, Bateman ED, Boulet LP, et al. A new perspective on concepts of asthma severity and control. Eur Respir J. 2008;32:545-554. [PubMed]
 
Gibson PG, Powell H, Ducharme F. Differential effects of maintenance long-acting β-agonist and inhaled corticosteroid on asthma control and asthma exacerbations. J Allergy Clin Immunol. 2007;119:344-350. [PubMed]
 
Thomas M, von Ziegenweidt J, Lee AJ, et al. High-dose inhaled corticosteroids versus add-on long-acting β-agonists in asthma: an observational study. J Allergy Clin Immunol. 2009;123:122-123. [PubMed]
 
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