Effect of smoking status on the efficacy of the SMART regimen in high risk asthma.

Abstract

We read with interest the article entitled ‘Effect of smoking status on the efficacy of the SMART regimen in high risk asthma’ by Pilcher et al.1 We would like to hear from the authors on the six following points. First, we do have a strong interest on how the authors determined the sample size and study period and the ratio of current smokers, ex-smokers and never smokers. Second, the authors presented ‘onset of respiratory symptoms after the age of 40 in current and ex-smokers with a >10 pack year-smoking history as the exclusion criteria of patients with COPD’. We do think that responsiveness to beta2-stimulant must be essential to diagnose bronchial asthma. We would like to hear from the authors whether they evaluated the responsiveness. Third, we would appreciate hearing from the authors as to how many patients used systemic corticosteroid therapy before inclusion of this study. Were there any differences in the prescription of systemic corticosteroid between the two study groups? Fourth, 17 and 11 patients with SMART and Standard groups discontinued this study, respectively. What were the reasons of discontinuation? Fifth, we would like to know how the authors evaluated the safety profile of the SMART regimen. Sixth, as the authors described, it is well known that individuals with asthma who smoke benefit less from inhaled corticosteroid and oral corticosteroid therapy in terms of symptoms, lung function and risk of severe exacerbations.2-7 We would like to ask the authors whether the results of the present study imply that SMART regimen overcomes the influence of smoking. Furthermore, asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) has attracted attention in recent years.8, 9 When thinking of smoking status on asthma in clinical practice, the overlap of COPD might not be avoided. We would like to ask the authors whether the results of the present study imply that SMART regimen is also beneficial for ACOS patients.