Teaching old drugs new tricks: asthma therapy adjusted by patient perception or noninvasive markers

Abstract

Asthma management is having a makeover. Three very different treatment approaches are parading the conference catwalks. Each uses long-acting β-agonists (LABA) and inhaled corticosteroids (ICS) as the basis of maintenance therapy. However, they differ substantially in how the treatment is adjusted, and in what outcomes have been reported. One approach advocates escalating ICS doses to achieve physician-assessed symptom control 1 and has recently been reviewed in the European Respiratory Journal 2. Another advocates the use of objective markers of airway inflammation (induced sputum, airway hyperresponsiveness) to adjust treatment 3, 4, and the third approach lets the patient off the leash to use LABA/ICS as needed for short-term symptom management 5. The limitations of our current treatment approaches for asthma are well known 6, and each of these new approaches has been found to be superior to their comparator in well-conducted randomised controlled trials. So, there is a sense of optimism and excitement surrounding these different approaches to asthma management. But do they constitute a new summer frock, working with and enhancing what we have, or are they more like cosmetic surgery, artificially covering a decay in asthma management that results from a mismatch between expectation and reality? Asthma is a variable disease, and exacerbations are responsible for a disproportionate amount of the morbidity and mortality from asthma. Current management approaches have limited efficacy for exacerbations 7. Doubling ICS doses has not been shown to be effective for exacerbation management 8, and intensive self-management programmes are required to reinforce adherence and reduce exacerbations 9. Using these approaches, an emergency department visit for asthma can be prevented in one out of every 22 patients who complete an asthma self-management programme (number needed to treat (NNT) = 22) 9. Several limitations to this approach are that …