Corticosteroids In Asthmatic Patients Research Articles

Family Physicians’ Awareness of the Burden of Oral Corticosteroids in Asthma Patients

Objective. The objective of this study was to identify when family physicians decide to prescribe oral corticosteroids (OCS) to treat asthma, to establish the factors affecting their decision, and how familiar family physicians are with the side effects of OCS. Materials and Methods. A cross-sectional observational study was conducted among physicians that are members of the Slovenian Family Medicine Society. Results. The study included 122 family physicians from all 12 Slovenian regions. The great majority (86.9%) reported they had previously prescribed OCS to asthma patients. The largest share of these (45.1%) tended to prescribe a limited number of tablets, although many (42.6%) also prescribed the entire pack. Regarding the adverse effects associated with OCS, the physicians listed a range of potential problems, highlighting hyperglycemia and exacerbated diabetes, the impact on bone density, a suppressed immune system and increased risk of infection as the most common. Conclusion. In the future, it is vital to improve family physicians’ awareness of when OCS may be prescribed to treat severe asthma, and to define the clinical pathway for severe asthma, which should also involve interdisciplinary collaboration.

Biomarker-guided withdrawal of inhaled corticosteroids in asthma patients with a non-T2 inflammatory phenotype – a randomized controlled trial study protocol

BackgroundNon-T2 asthma is characterized by the absence of elevated type 2 inflammatory biomarkers such as blood-eosinophils, total and allergen-specific Immunoglobulin E and Fractional exhaled Nitric Oxide (FeNO). According to guidelines, inhaled corticosteroids (ICS) are the cornerstone of asthma management. However, ICS treatment is associated with a risk of local side effects, including hoarseness and thrush, and long-term high-dose therapy may cause systemic adverse effects. Furthermore, whereas treatment with ICS is highly effective in T2 asthma, studies have shown a markedly reduced ICS efficacy in patients with a lower degree of T2 inflammation, thus posing a clinical challenge in this subgroup of patients. Hence, owing to the ICS dosage step-up approach in current clinical guidelines, patients with low T2 biomarkers are at risk of being exposed to high doses of ICS, and by that at risk of side effects. Thus, an ICS-treatment regime guided by biomarkers that reflects the inflammatory phenotype is warranted in order to reduce the corticosteroid burden in patients with non-T2 asthma. This study combines a panel of non-T2 inflammatory markers (low periostin, low blood-eosinophils, and low FeNO), to determine if this group of patients can maintain asthma control during ICS withdrawal.MethodsThis is an ongoing prospective multicenter open-label randomized, controlled trial aiming to assess if ICS can be safely tapered in patients with non-T2 asthma. The patients are randomized 1:1 to either standard of care or an ICS tapering regimen (n = 55 in each group) where the initial ICS dose is reduced by 50% for 8 weeks followed by total ICS removal. The primary endpoint is change in asthma control questionnaire (ACQ) from baseline to post-tapered ICS. The secondary endpoints are time from baseline to drop-out caused by loss of asthma control, changes in serum-periostin, blood-eosinophils, FeNO, Forced Expiratory Volume in 1 s (FEV1) and in sputum-eosinophils.DiscussionThis study aims to provide data on ICS tapering in non-T2 asthma patients and to contribute to a more individualized and corticosteroid-sparing treatment regime in this group of patients.Trial registrationClinicaltrials.gov Identifier: NCT03141424. Registration date: May 5th, 2017.

Microsphere as a novel strategy for the long-term use of corticosteroids in asthma patients during the COVID-19 Pandemic

Microsphere as a novel strategy for the long-term use of corticosteroids in asthma patients during the COVID-19 Pandemic

Microsphere as a novel strategy for the long-term use of corticosteroids in asthma patients during the COVID-19 Pandemic

The use of corticosteroids during the (Coronavirus Disease 2019) COVID-19 has become a new concern. Corticosteroids are the main therapy in asthmatic patients with anti-inflammatory and immunosuppressant effects. Patients with the need for long-term use of corticosteroids, such as asthma patients, are aware of the risk from infection obtained by the side effect of long-term corticosteroid use. A Recent study has innovated a new drug delivery agent, called Microsphere that can specify the targeted therapy. This new therapy may potentially increase the treatment efficacy with the lesser side effects. Here we review a study that uses the Microsphere for delivering corticosteroids. Additional studies are warranted to support the use of Microspheres as novel drug delivery for asthma patients during the COVID-19 pandemic.

COVID-19 risk and outcomes in adult asthmatic patients treated with biologics or systemic corticosteroids: Nationwide real-world evidence

BackgroundManaging severe asthma during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is challenging, particularly due to safety concerns regarding the use of systemic corticosteroids and biologics.ObjectivesWe sought to determine the association between biologics or systemic corticosteroids use and PCR positivity for SARS-CoV-2 and coronavirus disease 2019 (COVID-19) outcomes among asthmatic patients.MethodsWe used the computerized database of Clalit Health Services, the largest health care provider in Israel, to identify all asthmatic adult patients who underwent PCR testing for SARS-CoV-2, between March 1, 2020, and December 7, 2020. A cohort approach was used to assess the association between biologics use and steroids treatment and COVID-19 severity and 90-day mortality.ResultsOverall, 8,242 of 80,602 tested asthmatic patients had positive PCR testing result for SARS-CoV-2. Both biologics and systemic corticosteroids were not associated with increased risk of SARS-CoV-2 infection. Multivariate analyses revealed that biologics were not associated with a significantly increased risk of moderate to severe COVID-19, nor with the composite end point of moderate to severe COVID-19 or all-cause mortality within 90 days. Chronic systemic corticosteroid use was associated with significantly increased risk of all tested outcome. Recent (within the previous 120 days) systemic corticosteroid use, but not former use, was significantly associated with increased risk of both moderate to severe COVID-19 and the composite of moderate to severe COVID-19 or all-cause mortality.ConclusionsBiologics approved for asthma and systemic corticosteroids are not associated with increased risk of SARS-CoV-2 infection. In contrast, systemic corticosteroids are an independent risk factor for worst COVID-19 severity and all-cause mortality. Our findings underscore the risk of recent or current exposure to systemic corticosteroids in asthmatic patients infected with SARS-CoV-2.

Challenges in the diagnosis, treatment and management of asthma during COVID-19 pandemic

Abstract People over the age of 65 and those suffering from chronic diseases, such as asthma, are part of the risk group for severe acute respiratory syndrome-COV-2 (SARS-CoV-2) infection. In the past, a connection between viral infections and asthma has been presented. Patients with asthma appear to be at risk of contracting viral infections, and also viruses can cause asthma exacerbations. Another concern during this period was about the chronic administration of corticosteroids in asthmatic patients, because of the consideration that corticosteroid therapy would decrease the immunity of these patients, thus increasing the risk of infections, including the infection with SARS-CoV-2. Thus, several questions have emerged about the role of corticosteroid therapy in the development of COVID-19 in patients undergoing corticosteroid treatment. Most guidelines recommend continuing the administration of chronic treatment to this category of patients. At the same time, the health system had to adapt to the situation caused by the COVID-19 pandemic and deviate from the standard methods of managing most chronic diseases and these changes had an impact on these category of patients.

How to maintain oral health in children with respiratory diseases: Literature review

The most frequent chronic respiratory problems in childhood are asthma and cystic fibrosis (CF). The purpose of this paper is to review basic knowledge and recent advances in oral health and associated dental morbidities in children with asthma and CF. This review considered clinical trials and systematic reviews related to oral health in children with CRD. An online base Medline was searched to determine relevant papers, using the combination of the following terms: 'asthma', 'cystic fibrosis', 'caries', 'dental erosion', and 'oral health'. Oral health problems in children with chronic respiratory diseases (CRD) may be influenced by natural course of the disease, pharmacotherapy (inhalation therapy with bronchodilators and inhaled corticosteroids in asthmatic patients, systemic antibiotics and pancreatic enzyme replacement therapy in CF patients), medication administration technique and nutritional habits. Children with CRD may have higher prevalence of oral diseases. Patients and their parents, but also general paediatricians and pulmonologists, should be aware of importance of good oral health. Dental practitioners should be more informed about risk factors and specificities of oral health in these patients. Preventive measures, early diagnosis and effective treatment strategies in children with CRD can reduce occurrence of oral diseases and improve patient's quality of life.

Assessing adherence to inhaled corticosteroids in asthma patients using an integrated measure based on primary and secondary adherence.

There are very few studies on primary adherence (i.e., first filling of a prescription) to inhaled corticosteroids (ICS) in asthma patients; two have involved children. Moreover, adherence can be overestimated when considering only secondary adherence (i.e., following the medication recommendations for a defined period) and ignoring primary adherence. We aimed thus to evaluate the real-world primary and secondary adherence to ICS and to develop an integrated primary and secondary adherence (IPSA) measure. From two clinical databases of pediatric and adult asthma patients, we included 198 children and 206 adults with one ICS prescription recorded in their medical chart between 2010 and 2012 and follow-up data for ≥12months. Adherence was estimated from written prescriptions and prescription claims data. Primary adherence was defined as filling the ICS prescription at a pharmacy within 12months. Secondary adherence was defined as the proportion of days covered (PDC) in subjects who filled their prescription at least once. The IPSA was based on the PDC with a correction factor for primary adherence. Primary adherence to ICS at 12months was 89.4% in children and 69.4% in adults. Secondary adherence at 12months in children was 33.9%, and the IPSA was 30.3%. These values were 52.8 and 36.6%, respectively, in adults. Primary adherence to ICS is low in adults and secondary adherence is poor in children and adults. Using the PDC as a unique measure of adherence led to significant overestimation in adults; IPSA leads to more valid estimates of adherence to ICS.

Inhaled corticosteroids and incident pneumonia in patients with asthma: Systematic review and meta-analysis.

To systematically review all available studies on inhaled corticosteroid use and incident pneumonia in asthma patients. We performed a literature search from January 1, 1993, through August 15, 2015, using PubMed, Medline, CENTRAL, EMBASE, Scopus, ISI, Regulatory Documents, Web of Science and manufacturers' web clinical trial registries with multiple search terms. We included studies that compared the risk of incident pneumonia among patients utilizing and not utilizing inhaled corticosteroids. We then summarized risk estimates into two random-effect meta-analyses; one including randomized controlled trials and another one including observational studies. Fourteen studies were estimable; ten randomized controlled trials included 19,098 participants and four observational studies included 44,016 participants. There was no heterogeneity in randomized trials and summed risk ratio demonstrated the use of inhaled corticosteroids was protective of pneumonia; risk ratio 0.74, 95% CI 0.57 to 0.95, p=0.02. On the contrary, observational studies showed summed odds ratio of 1.97; 95% CI 1.87 to 2.07, p<0.0001, I²=0%, suggesting increased risk of pneumonia with use of inhaled corticosteroids in asthma patients. Inhaled corticosteroids are associated with decreased risk of incident pneumonia in patients with asthma based on meta-analysis of available randomized trials. Although observational studies in similar patients suggested higher risk of pneumonia, the inherent methodological limitations confer lower grade of confidence in these studies.

Association between WDR21A polymorphisms and airway responsiveness to inhaled corticosteroids in asthmatic patients

Genetic polymorphism is partially responsible for the wide variation in the response of moderate-to-severe asthmatic patients to inhaled corticosteroids. The goal of the study was to examine polymorphisms in WDR21A, which encodes a putative glucocorticoid receptor (GR)-interacting protein, for their possible association with corticosteroid responsiveness. The change in forced expiratory volume in 1 s [FEV(1) (ΔFEV(1))] induced by 4 weeks of inhaled treatment with fluticasone propionate (1000 µg daily) was measured in 230 asthmatic patients. Fifteen single nucleotide polymorphisms (SNPs) of WDR21A were genotyped using a TaqMan assay, and 11 SNPs were used for further analysis. WDR21A transcripts were analyzed for variant splicing using reverse transcriptase-PCR. The WDR21A protein structure was predicted using a template-based modeling method and docked to a GR using Zdock. Of the 11 SNPs and three haplotypes of WDR21A analyzed, only the intronic SNP -10073G>C appeared to affect ΔFEV(1). The ΔFEV(1) of the -10073C/C homozygous genotype was twice that of the -10073G/G and -10073C/G genotypes (P(corr)=0.04 in recessive model). No splicing variant of WDR21A was observed, regardless of genotype. The predicted WDR21A protein structure was similar to the Gβ(1) protein structure (template modeling-score=0.93). The minor allele -10073C of WDR21A may induce a good response to inhaled corticosteroids possibly through competition with the Gβ(1) proteins for binding to GRs.

Combination therapy with single inhaler of long-acting β2-adrenoceptor agonists/inlaled corticosteroids compared with higher dose of inhaled corticosteroids in asthmatic patients

Objective To provide a quantitative summary estimate on the efficacy and safety measures of the combination therapy.Methods We searched databases(Medline and Embase)from January 1997 to December 2009 using‘ Fluticasone and salmerterol' or‘ Seretide' or‘ Advair' or‘ budesonide/formoterol' or‘ Symbicort Turbuhaler' in combination with ‘ Randomised controlled trial'.The databases of GlaxoSmithKline Clinical Trial Register and Cochrane Controlled Trials Register,or relevant original studies and review articles were approached for additional studies or details of all relevant studies.Results Morning peak expiratory flow(PEF),evening PEF and clinic FEV1 were 17.59L/min,14.95L/min and 0.08L/min higher with combination therpy than with increasing ICSs by two fold or more at endpoint,respectively.The risk of asthmatic exacerbation was reduced in the combination therpy group compared with the increased doses of ICS groups,with OR being 0.61(95 ％ CI 0.53 ～ 0.70,P ＜ 0.01).Significantly increases in the percent of symptom-free days 6.30(95％ CI 3.52 ～9.10),asthma-control days 9.49(95％ CI 4.74 ～14.25)and relieve-free days 6.59(95％ CI 6.10 ～ 7.08)were observed in patients treated with ICS/LABA compared with increased doses of ICSs at endpoint.Reduction in reliever medication use(inhalations/day)0.22(95 ％ CI 0.11 ～0.33)with significant difference was also observed at endpoint.Conclusion Combination products of ICS/LABA were more effective than a high dose of ICSs in improving lung function,reducing asthmatic exacerbation and use of reliever medication and improving control of asthma. Key words: Asthma; Glucocorticoids Inhaled; Receptors,adrenergic,beta-2; Adrenergic,beta-agonists; Administration, inhalation; Meta-analysis

Usefulness of PBMCs to predict clinical response to corticosteroids in asthmatic patients

Blood tests are needed to identify steroid-resistant (SR) asthmatic patients early so that they can be managed with alternative anti-inflammatory therapy. We sought to assess the usefulness of peripheral blood to predict steroid response in asthmatic patients. Nineteen asthmatic patients with FEV(1) of less than 80% of predicted value were classified as SR or steroid sensitive (SS) based on change in lung FEV(1) percentage after 7 days of oral prednisone. Blood was collected at baseline (visit 1) and 30 days after prednisone administration (visit 3). PBMCs were cultured for 4 hours with or without 10(-7) mol/L dexamethasone, and cellular response to dexamethasone was determined by using real-time PCR based on expression analysis of steroid-regulated genes. Suppression of PHA-induced T-cell proliferation by dexamethasone was assessed. Prednisone significantly improved FEV(1) percentages in SS asthmatic patients (mean ± SE: 17.5% ± 2.4%) but not SR asthmatic patients (0.8% ± 2.0%, P< .001). Before prednisone treatment, mitogen-induced kinase phosphatase 1 (P= .01) and IL-8 mRNA (P< .05) levels were significantly higher in PBMCs from SR asthmatic patients. TNF-α (P< .05) and IL-8 fold suppression by dexamethasone (P< .05) were significantly reduced in PBMCs from SR asthmatic patients. The expression of glucocorticoid receptor (GCR) β, but not GCR-α, was significantly increased in PBMCs of SR asthmatic patients (P= .01). The dexamethasone inhibitory concentration of 50% for PBMC proliferation was significantly higher for SR asthmatic patients (P< .05). These markers no longer differed between groups in PBMCs 30 days after prednisone administration. The composite score of assays at baseline before prednisone was significantly different between SR and SS asthmatic patients (P< .001). PBMCs from SR asthmatic patients have higher baseline mitogen-induced kinase phosphatase 1, IL-8, and GCR-β mRNA levels; have a lower GCR-α/GCR-β mRNA ratio; are less responsive to suppression of TNF-α and IL-8 by dexamethasone; and require more dexamethasone to suppress T-cell proliferation compared with SS asthmatic patients.

Statins enhance the anti-inflammatory effects of inhaled corticosteroids in asthmatic patients through increased induction of indoleamine 2, 3-dioxygenase

We have previously shown that inhaled corticosteroids activate indoleamine 2, 3-dioxygenase (IDO) activity through increased IL-10 secretion. Statins might enhance the anti-inflammatory effects of corticosteroids. In a double-blind study we added simvastatin to patients with mild asthma receiving a low dose of inhaled budesonide and evaluated sputum eosinophil counts, IL-10 secretion, and IDO activity, as well as their putative signaling pathways. After a 2-week run-in period without treatment, 50 asthmatic patients were treated with 200 μg of budesonide and randomly assigned to either 10 mg of simvastatin or matched placebo for 8 weeks. Inflammation was evaluated through eosinophil counts, secretory signaling molecules, and immunocytochemistry of macrophages in sputum. Sputum eosinophil percentages were reduced significantly by the combined therapy with budesonide and simvastatin compared with budesonide alone (P= .02). Corticosteroids activated glucocorticoid-induced TNF receptor ligand, which induces activation of p52 through the noncanonical nuclear factor κB pathway, leading to the increased transcription and activation of IDO. Simvastatin enhanced corticosteroid-activated noncanonical nuclear factor κB-dependent induction of IDO by activating type I interferons and also enhanced the effect of corticosteroid on IL-10 release. A statin enhances the anti-inflammatory effect ofan inhaled corticosteroid in asthma, and this was mediated through the alteration of IDO activity in macrophages.

Churg-Strauss syndrome in a child with IgA nephropathy

Churg-Strauss syndrome (CSS) is a rare systemic vasculitis associated with asthma and eosinophilia. Withdrawal of corticosteroids in asthmatic patients is known to be a powerful trigger for the development of CSS. Renal involvement in patients with CSS is commonly manifested as antineutrophil cytoplasm antibody-associated necrotizing crescentic glomerulonephritis, however, concomitant CSS and the nephrotic syndrome or IgA nephropathy are rare. We report a 12-year-old boy with CSS associated with IgA nephropathy that developed while tapering oral steroids. The patient had a history of the nephrotic syndrome and asthma.

Evaluating the Safety of Intranasal Steroids in the Treatment of Allergic Rhinitis

Given that intranasal corticosteroids (INCs) are widely considered first-line therapies for treatment of rhinitis, it is important for the clinician to be comfortable with the side-effect profile and be able to discuss potential safety concerns regarding these therapies. Among the safety concerns with the use of INCs are the potential for growth suppression both short and long term, the potential for hypothalamic-pituitary-adrenal axis suppression, ocular safety, and the use of INCs concomitantly with inhaled corticosteroids in asthma patients. As all clinicians are aware, each patient can have individual responses to both efficacy and safety; however, the data reviewed suggest that the benefits outweigh the potential risks. Understanding the potential concerns and the data behind these concerns should give clinicians the information to be able to discuss this with patients and parents to incorporate appropriate therapy for those with allergic rhinitis

Personality Influences the Reporting of Side Effects of Inhaled Corticosteroids in Asthma Patients

Rationale. Negative affectivity is a measure of anxiety associated with increased reporting of symptoms. Few studies have explored this association with respect to drug-induced symptoms in patients taking medication for a chronic disease in real life. Objectives. In this cross-sectional study we examined the relationship between negative affectivity and self-reported side effects of inhaled corticosteroids in patients with asthma. We also investigated differential associations due to side effect type (subjective versus observable side effects) and treatment impact (i.e., hierarchical dosing). Methods. A total of 228 asthma patients, taking inhaled corticosteroids, completed scales measuring inhaled corticosteroid-induced side effects (Inhaled Corticosteroid Questionnaire scored: 0 = none; 100 = worst) and negative affectivity (Positive and Negative Affect Schedule scored: 10–50). Patients were grouped into low, average, and high negative affectivity groups based on published norms. Results. Patients high in negative affectivity reported significantly greater (p < 0.001) side effects (median score 20.5 (IQR: 11.4–33.0) than the groups of patients scoring lower on this measure (low negative affectivity: 7.1 (3.1–15.6); average: 13.3 (4.9–23.3)). The relationship between negative affectivity and side effects was stronger among patients taking low (r = 0.40–0.45) rather than mid to high inhaled corticosteroid doses (r = 0.16–0.28). Conclusions. Asthma patients with higher negative affectivity using inhaled corticosteroids report increased medication-induced symptoms. Clinicians should be aware that aside from inhaled corticosteroid dosage, the personality of the patient is an important factor in the reporting of drug-related side effects.

Adherence with inhaled corticosteroids in asthma patients receiving fluticasone propionate/salmeterol in a single inhaler versus add-on salmeterol inhaler or add-on montelukast

Adherence with inhaled corticosteroids in asthma patients receiving fluticasone propionate/salmeterol in a single inhaler versus add-on salmeterol inhaler or add-on montelukast

Effect of Transdermal Tulobuterol Added to Inhaled Corticosteroids in Asthma Patients

Tulobuterol tape is the first long-acting transdermal preparation of a p2-agonist designed to release tulobuterol in an optimal fashion over a 24-hour period. We investigated the additive effect of tulobuterol tape in adult asthma patients treated with inhaled corticosteroids. A randomized, double-blind, double-dummy, parallel-group, multicenter trial was conducted. Male and female patients with a diagnosis of asthma requiring inhaled short-acting β2-agonists despite treatment with inhaled corticosteroids took tulobuterol tape (1 mg or 2 mg) and corresponding placebo tapes for 4 weeks. Results: Mean morning peak expiratory flows (PEF) in the 1 and 2 mg/day groups were significantly increased from the baseline value by 23.8 and 35.9 L/min at week 4, respectively. The increase in mean morning PEF in the 2 mg/day group was significantly higher than that in the 1 mg/day group. The mean evening PEF was significantly increased in both treatment groups compared with baseline values. Although the increase in mean evening PEF in the 2 mg/day group was greater than that in the 1 mg/day group, the difference between groups was statistically significant only at week 1. The safety profiles of the two treatments were similar. Conclusions: In patients with persistent asthma who require inhaled short-acting β2-agonists while receiving inhaled corticosteroids, transdermal tulobuterol significantly improved PEF in a dose-dependent manner, i.e., greater effect with 2 mg than with 1 mg per day.

Voice problems as side effects of inhaled corticosteroids in asthma patients—a prevalence study

Voice disturbances in asthma patients may be caused by inhaled corticosteroids. In order to study the prevalence of such voice disturbances, a questionnaire was delivered to asthma patients at three asthma and allergy departments in Stockholm. The questionnaire consisted of 25 questions concerning the asthma disease symptoms, medication, voice function, and voice disturbances. A total of 350 questionnaires were delivered. Response frequency was 80%. There was a significant positive correlation between inhalation of cortison and voice disturbances. Most of the patients complained about hoarseness, followed by throat clearing, a lump in the throat, loss of voice, and less frequently, throat pain. There were no significantly differences between men and women. Elderly had more voice problems than young persons. Patients with voice-demanding professions had more problems than patients who used their voice to a lesser extent during the working day. There was a significant positive correlation between high cortison doses and voice problems as well as between voice problems and acid regurgitation.

The inflammatory marker serum eosinophil cationic protein (ECP) compared with PEF as a tool to decide inhaled corticosteroid dose in asthmatic patients

The objective of this study was to compare the inflammatory marker eosinophil cationic protein (ECP) with peak expiratory flow (PEF) in determining the therapeutic needs of inhaled corticosteroids in asthma patients assessed as asthma symptoms. A randomized, single-blind study over 6 months was performed at six specialist centres in Europe. In total, 164 adult patients with moderate to severe symptomatic asthma and regular use of inhaled corticosteroids were included. After a run-in period of 2 weeks patients were randomly allocated to the ECP or the PEF monitoring group. The dose of inhaled corticosteroids was adjusted every fourth week based on the current serum ECP value or pre-broncho-dilator morning PEF values as surrogate markers of therapeutic needs. At the end of the study there were no statistically significant differences in the mean daily symptom score or the percentage of symptom-free days between the two groups. The mean daily dose of inhaled corticosteroids was similar in the two groups at the start of the study but the algorithms used to adjust the dose of inhaled corticosteroids resulted in an increased use of inhaled corticosteroids in both groups. The mean daily dose of inhaled corticosteroids over the whole study period was significantly lower in the ECP group compared with the PEF group (1246 vs. 1667 μg,P =0·026). In the ECP group, forced expiratory volume in 1 sec (FEV1)% predicted was lower at the end of the study compared with the begining (92% vs. 87%, P=0·0009), although there was no significant difference between the two groups. None of the used algorithms for ECP and PEF led to improvement in symptom scores, in spite of increased doses of inhaled corticosteroids. In this respect, both methods were equivalent and insufficient. Recommendations suggesting lung function tests in current guidelines may be difficult to translate into clinical practice, however, a combination of inflammatory markers, lung function and symptoms may still improve asthma control.