PURPOSE: Inhaled corticosteroids (ICS) are the safest, most effective anti-inflammatory treatment for asthmatics. Yet, we could find no studies on prophylactic ICS use to prevent asthma and other respiratory diseases after inhalation exposures. We hypothesized that ICS, started shortly after exposure to World Trade Center (WTC) dust and combustion by-products would prevent or reduce persistent respiratory symptoms, airway hyperreactivity (AHR) and lung function decline.
METHODS: One week post-attack, budesonide by turbuhaler, was offered to NYC firefighters. Proper use was demonstrated and instructions given as to safety profile, off-label use for this IRB approved study and dose (2 puffs daily for 4 weeks). 2 years post-WTC, the treated group was evaluated for persistent respiratory symptoms (St. Georges Respiratory Questionnaire), AHR (PC20 <8mg methacholine) and lung function decline (FEV1) as compared to case controls (matched for WTC arrival time as an exposure severity surrogate, pre-WTC FVC and FEV1, age, work years and tobacco status) who did not receive ICS.
RESULTS: 2,991 of ∼11,000 (27%) firefighters agreed to enroll, but only 220 (7%)completed 4 weeks of treatment. The most common reason for not enrolling was “steroid fear” and for not completing was “no immediate effect”. No side effects were reported. Although matched for WTC arrival time, the treated group reported greater number of unprotected hours without a respirator between 9/11-9/17/01 (prior to enrollment). Pulmonary function was normal. Two years post-WTC, the treated group reported significantly greater declines in respiratory symptom severity scores, but without significant differences FEV1 decline rates or AHR when compared to controls (table).
CONCLUSION: Prophylactic ICS use reduced respiratory symptoms and improved quality of life but did not affect pulmonary functions (decline rate or AHR). Improvement occurred despite greater respiratory exposure in the treated group.
CLINICAL IMPLICATIONS: Respiratory protection is the primary means for preventing lung injury but prophylactic ICS should be considered after high-risk exposures given ease of use, safety profile and improvement in respiratory symptoms. Pre-treatment education must focus on proper use and correcting misperceptions interfering with enrollment/treatment.
DISCLOSURE: David Prezant, Grant monies (from industry related sources) This research was conducted with support from the Investigator-Sponsored Study Program of AstraZeneca; Product/procedure/technique that is considered research and is NOT yet approved for any purpose. The use of an inhaled corticosteroid for prophylactic purposes may be considered off-label use.