Does doubling the dose of inhaled corticosteroids prevent asthma exacerbations?*1

Abstract

Many asthma management guidelines stress the importance of self-management plans to be used by suitably instructed patients in the overall care of asthma. In asthmatic individuals treated chronically with inhaled corticosteroids (ICSs), some self-management plans recommend doubling the maintenance dose of ICS when there is evidence of significant worsening of asthma symptoms or peak expiratory flow rates. But is there convincing evidence that doubling the dose of ICS will prevent further worsening of the asthma to the point of an acute exacerbation? This study investigated a group of 390 asthmatic individuals receiving chronic ICS therapy who were at increased risk for acute asthma exacerbations on the basis of their past medical histories. In a randomized, blind, parallel, controlled protocol, each of the patients added either a doubling dose of ICS or placebo at signs of worsening asthma. The primary study outcome was the percentage of individuals requiring use of a “burst” treatment with oral corticosteroids for an acute exacerbation of asthma during the 12-month study period. During this period, 53% of the patients felt the need to add inhaler therapy (doubling dose of ICS or placebo). A course of oral corticosteroids was subsequently needed in 11% of those adding ICS and in 12% of those adding placebo. The authors concluded that these findings did not support a beneficial effect in preventing asthma exacerbations for the addition of a doubling dose of ICS when asthma worsened. However, it was not clear whether the asthma symptoms and/or quality of life improved faster in those adding the doubling dose of ICS. Moreover, it is unclear whether the effect of doubling the dose of ICS was related to the baseline ICS dose in individual patients. A number of studies have shown that the beneficial effects of most ICSs begin to plateau at doses above 800-1000 μg/day in asthmatic adults.