Can Inhaled Corticosteroids Prevent Asthma Exacerbations?

Dhananjay Desai; Salman Siddiqui; Christopher Brightling

Disclosures

Curr Opin Pulm Med. 2011;17(1):16-22. 

In This Article

Asthma Exacerbations: Biomarkers to Direct Therapy

ICS is more favourable in patients with evidence of eosinophilic inflammation and corticosteroid reduction studies have consistently shown that induced sputum eosinophilia precedes asthma exacerbations[59] suggesting that strategies targeting sputum eosinophilia can effectively reduce exacerbations.

Three clinical studies have compared symptom and guideline-based asthma management to a sputum eosinophil-based strategy. Green et al.[60] conducted a randomized placebo controlled study in which 74 patients with moderate to severe asthma were assigned to standard clinical management according to national guidelines or a sputum-based strategy group with treatment targeted at normalizing the sputum eosinophil count. Patients in the sputum management group had both fewer asthma exacerbations and admissions compared to the guideline management group. Chlumský et al.[61] conducted a prospective randomized controlled study of sputum-based management targeting eosinophils vs. standard clinical asthma management in 55 patients with moderate to severe persistent asthma. Targeting eosinophilia led to a significant reduction in exacerbations (defined as a doubling in symptom frequency/bronchodilator use) compared to the control group. In 117 patients, Jayaram et al.[62] conducted a 2-year follow-up multicentre, randomized, parallel group effectiveness study. Treatment directed at normalizing the sputum eosinophil count also led to a reduction in exacerbations and increased the time to first exacerbation by 213 days. The reduction in exacerbations was more apparent in those with moderate to severe disease. This suggests that it is probably most appropriate to apply this technique to the management of difficult-to-treat or refractory asthma, but that its use may not be applicable to a primary care population of milder asthmatic patients.[63]

In contrast, approaches using alternative biomarkers such as exhaled nitric oxide to direct ICSs have not demonstrated benefit in reducing exacerbation frequency. Therefore in the absence of an adequate alternative to sputum assessment of airway inflammation this approach is recommended in difficult-to-treat asthma.[2]

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