Inhaled Steroids Reduce Asthma Relapse Rate
December 1, 1999 3 minutes read
Inhaled Steroids Reduce Asthma Relapse Rate
abstract & commentary
Source: Rowe BH, et al. Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department. JAMA 1999;281: 2119-2126.
Patients who presented to the ed with acute asthma exacerbations were evaluated in this randomized, placebo-controlled study. Patients were eligible to participate if they had a moderate-to-severe exacerbation, were able to be discharged from the ED, had uncomplicated disease, and had received no steroids (oral or inhaled) in the previous week. All study patients received a non-tapering course of oral prednisone (50 mg/d for 7 d). One-half of the patients were randomized in a double-blind fashion to receive inhaled budesonide (Pulmicort), two puffs twice a day (1600 mg total daily dose); the other half received a matching placebo inhaler. Other than steroid therapies, all ED and post-discharge management was dictated by the treating physician. The primary outcome was relapse at 21 days.
Of 1006 consecutive ED visits for asthma, 188 patients were eligible and consented to enrollment. (Almost one-half were ineligible because they were already receiving oral or inhaled steroids.) The 21-day relapse rate was 13% in the inhaled steroid group vs. 25% in the placebo group (P < 0.05). Those in the budesonide group also used inhaled ß-agonists less frequently and had fewer symptoms and better quality of life and global assessment scores than the placebo group at 21 days. There was no difference, however, in pulmonary function. The budesonide group’s improvement in relapse rates became apparent by day 10. Rowe and colleagues conclude that budesonide added to oral corticosteroids benefits patients discharged from the ED with acute asthma exacerbation.
Comment by David J. Karras, MD, FAAEM, FACEP
This is one of the few studies published annually that justifies a change in our daily practice of emergency medicine. There is a substantial body of evidence showing that inhaled corticosteroids are effective in outpatients with asthma.1 Because steroid therapy is the standard of care for discharged ED patients, however, comparison of inhaled steroids to placebo therapy is not relevant to our practice. Several others have compared inhaled to oral steroids, finding such therapies to be equivalent. This study, in contrast, has shown that combined oral and inhaled steroid therapy is dramatically more effective than oral therapy alone. The reduction in 21-day relapse rate of nearly 50% suggests that only nine patients would require treatment to avert one relapse—similar to the decline in relapse rates seen when oral steroids were compared to placebo.2 While it would have been nice if Rowe et al had detected an improvement in pulmonary function in the budesonide group, we know that such objective indices often do not correlate well with patients’ perceptions of disease severity. Inhaled steroids have few significant side effects and appear to be warranted for routine use in acute asthma exacerbation.
References
1. Salmeron BJ, et al. High dose inhaled corticosteroids in unstable asthma. Am Rev Respir Dis 1989;140: 167-171.
2. Rowe BH, et al. Corticosteroids for preventing relapse following acute exacerbations of asthma: A meta-analysis. www.update-software.com/ccweb/cochrane.
Each of the following regarding acute asthma therapy is true except:
a. inhaled steroids may be as effective as oral steroids.
b. pulmonary function tests improve when inhaled steroids are prescribed.
c. inhaled steroids are effective in preventing relapse when added to oral steroids.
d. adding inhaled to oral steroids results in better quality-of-life scores.
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