ROLE OF SYSTEMIC AND INHALED GLUCOCORTICOIDS IN ASTHMA

Abstract

The National Institutes of Health Expert Panel Report 2, Guidelines for the Diagnosis and Management of Asthma (EPR2), categorizes asthma medications into those that provide quick relief and those that are used for long-term control of the disease.27 In EPR2, asthma is considered as mild and intermittent if symptoms occur twice weekly or less frequently and pulmonary function is normal between episodes. These patients are appropriately treated with as-needed inhaled beta-agonists to relieve symptoms. If asthma symptoms occur more often than twice weekly, if there is nocturnal awakening as often as twice a month, or if pulmonary function testing between episodes of asthma shows evidence of airflow obstruction, the patient is considered to have persistent asthma and to be a candidate for treatment with a long-term control medication that should have anti-inflammatory properties.27 In the latter category EPR2 recognizes corticosteroids as the “most potent and effective anti-inflammatory medication currently available.”27 The inhaled forms are used in the long-term control of asthma, and systemic corticosteroids are often used to gain prompt control of the disease when initiating long-term therapy. The primacy of inhaled corticosteroids is emphasized in EPR2 at each level in the stepwise approach recommended for managing asthma. Thus for mild persistent asthma, either low-dose inhaled corticosteroids or, in children, cromolyn or nedocromil are preferred; for moderate and severe persistent asthma, medium to high doses of inhaled corticosteroids, with the possible addition of long-acting bronchodilators, are recommended.27 EPR2 also presents two approaches for gaining control of asthma. One approach is to begin treatment at the step appropriate to the severity of the patient's disease and to step up treatment if control is not achieved. The preferred approach, however, is to gain rapid control by administering anti-inflammatory therapy at a level higher than that suggested by the severity of the patient's symptoms. This can be accomplished either by initiating a short course of systemic corticosteroids along with inhaled corticosteroids or by initiating a medium-to-high dose of inhaled corticosteroids. Once control is gained, rapid step-down to the treatment appropriate for the patient's level of severity should be instituted. This article reviews the data to support this preeminent role of corticosteroids in the treatment of chronic persistent asthma and exacerbations of asthma in adults.