Comparative results of the use of ACTH, cortisone, and hydrocortisone in the treatment of intractable bronchial asthma and pulmonary emphysema

Abstract

A total of 163 patients with intractable asthma and pulmonary emphysema with bronchospasm were given 309 courses of ACTH, cortisone, or hydrocortisone. Complete or partial remission was observed in 82.3 per cent of the ACTH courses. Of the cortisone-treated patients, 86.2 per cent of the courses showed a similar response. Complete or partial relief of bronchospasm and dyspnea was observed in 96 per cent of the courses of hydrocortisone administered at a dosage level averaging 50 to 60 per cent of that employed with cortisone. The duration of remission induced by the short, intensive courses of either ACTH, cortisone, or hydrocortisone was generally short-lived, averaging approximately 2 to 3 weeks. No significant difference in the duration of remission induced by these hormonal agents was found. Patients with bronchial asthma generally manifested a more complete remission than those with the broncho-spastic type of pulmonary emphysema. The effects produced with hydrocortisone differed from that of cortisone in the following manner: (1) a swifter onset of therapeutic benefit, i.e., in 18 to 36 hours with hydrocortisone as compared to 4 to 5 days with cortisone, (2) a decreased dosage requirement of approximately one-half to two-thirds of the cortisone dosage for comparable effect, and (3) a significant reduction in the adverse side reactions, due in all probability to the decreased dosage employed. The best results from the use of hormonal therapy took place in the following two clinical entities: (1) patients in whom persistent bronchospasm was the result of exposure to seasonal factors such as pollen, and (2) patients in whom the asthmatic state had been previously moderately well-controlled but in whom intractable bronchospasm developed following an upper respiratory infection. Although short, intensive courses of ACTH or the steroids seemed preferable to maintenance therapy in these two groups, in 21 of the 30 patients with chronic intractable asthma, pulmonary fibrosis, and advanced pulmonary emphysema, clinical improvement was maintained for 9 to 24 months by a daily dose of 20 to 75 mg. of cortisone or hydrocortisone. The adverse side effects of administration of the corticosteroids and ACTH were generally lessened by a low-sodium diet, administration of potassium chloride, and the use of antibiotic drugs in the presence of bronchial and sinus infections. The effectiveness of hydrocortisone at approximately one-half the dosage level of cortisone was accompanied by a significant reduction in the incidence of adverse side reactions. One patient who took cortisone against advice for 3 months developed bilateral pulmonary tuberculosis. One fatality occurred in a patient with severe bronchial asthma after repeated courses of both ACTH and cortisone. Delirium accompanied by exhaustion, fever, and cardiorespiratory failure suggested an Addisonian-like crisis.