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Rescue Treatment in Asthma

2010; Elsevier BV; Volume: 137; Issue: 1 Linguagem: Inglês

10.1378/chest.09-1711

1931-3543

Y. Bogaerts, Rebecca De Pauw,

Chronic Obstructive Pulmonary Disease (COPD) Research

We read with great interest the clinical commentary in CHEST (June 2009) by Papi et al1Papi A Caramori G Adcock IM Barnes PJ Rescue treatment in asthma. More than as-needed bronchodilation.Chest. 2009; 135: 1628-1633Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar 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.2Papi A Canonica GW Maestrelli P BEST Study Group et al.Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma.N Engl J Med. 2007; 356: 2040-2052Crossref PubMed Scopus (285) Google Scholar 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.3Bateman ED Boushey HA Bousquet J GOAL Investigators Group et al.Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study.Am J Respir Crit Care Med. 2004; 170: 836-844Crossref PubMed Scopus (1483) Google Scholar 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. Rescue Treatment in Asthma: ResponseCHESTVol. 137Issue 1PreviewWe 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. Full-Text PDF