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Therapeutic controversies in the treatment of asthma
1Department of Pediatrics, National Jewish Center for Immunology and Respiratory Medicine, Denver, CO 80206.
Objective:
To introduce readers to the current controversial topics in the area of asthma therapy. Background is provided such that clinicians are aware of these issues and can make rational decisions.
Data Sources:
Pertinent articles were individually identified and reviewed from each journal.
Study Selection:
Relevant studies, determined by topic and other specific criteria, e.g., testing methodology, were included.
Data Synthesis:
Further investigation is required in the areas discussed. Systemic effects, specifically growth suppression (in children), adrenal suppression, and osteoporosis, have been demonstrated with high-dose inhaled glucocorticoids; however, the clinical relevance of such intravenous glucocorticoid formulations via nebulizer have not been demonstrated. Likewise, data on the equivalence of the inhaled glucocorticoids, with regard to efficacy and potential systemic effects, and the differences between metered-dose inhalers and dry powder inhalers, with regard to aerosol characteristics and drug delivery, are unclear. Theophylline, when used with inhaled beta-adrenergic agonists and systemic glucocorticoids for the treatment of acute asthma, as not been shown to provide clear benefit and may result in increased adverse effects. The use of regular (vs. "as needed" or prn) inhaled beta-adrenergic agonists, although shown in two studies to be detrimental to the control of asthma and result in an increased risk of death or near death caused by asthma, has not been conclusively demonstrated to be harmful.
Conclusions:
Monitoring for adverse effects and the use of techniques to minimize systemic absorption (spacers and mouth rinsing) are recommended when high-dose inhaled glucocorticoid therapy is used. Intranasal and intravenous glucocorticoid products are not recommended for administration via nebulizer because of safety concerns. Until further data are available, inhaled glucocorticoids are thought to be equivalent on a microgram-per-microgram basis rather than an actuation-per-actuation basis. Theophylline is no longer recommended for treatment of acute exacerbations in nonhospitalized patients not already receiving the medication, and the link between deterioration of asthma control (and the risk for death) and regular inhaled beta-adrenergic agonists appears weak.
Insights
Current asthma therapy guidelines are controversial. High-dose inhaled glucocorticoids require monitoring for side effects. Theophylline is not recommended for acute asthma exacerbations.
Area of Science:
- Pulmonology
- Pharmacology
- Clinical Medicine
Background:
- Asthma management involves complex therapeutic decisions.
- Clinicians require updated information on controversial asthma treatment topics.
- Evidence-based practice necessitates awareness of evolving treatment paradigms.
Purpose of the Study:
- To review current controversial topics in asthma therapy.
- To provide background information for rational clinical decision-making.
- To highlight areas requiring further investigation in asthma treatment.
Main Methods:
- Individual identification and review of pertinent articles from medical journals.
- Inclusion of relevant studies based on topic and specific criteria, including testing methodology.
- Synthesis of data to address controversial aspects of asthma pharmacotherapy.
Main Results:
- High-dose inhaled glucocorticoids may cause systemic effects (growth/adrenal suppression, osteoporosis); clinical relevance of nebulized formulations is unclear.
- Equivalence and delivery differences between inhaled glucocorticoid inhaler types (MDIs vs. DPIs) require further study.
- Theophylline offers no clear benefit and may increase adverse effects in acute asthma; regular use of inhaled beta-adrenergic agonists shows a weak link to asthma deterioration and mortality risk.
Conclusions:
- Monitor for adverse effects and use techniques to minimize systemic absorption with high-dose inhaled glucocorticoids.
- Avoid nebulized intranasal and intravenous glucocorticoid products due to safety concerns.
- Inhaled glucocorticoids are considered equivalent microgram-per-microgram; theophylline is not recommended for acute exacerbations; regular inhaled beta-agonists' link to severe asthma is weak.