Evidence for benefits of early intervention with non-steroidal drugs in asthma

Earlier guidelines recommended the use of bronchodilators, such as beta 2-agonists, in patients with mild asthma (defined as having symptoms present on < or = 3 days per week), the use of sodium cromoglycate in moderately severe asthma patients (symptoms present on > 3 days per week), and inhaled corticosteroids in those not satisfactorily controlled by sodium cromoglycate (severe asthma). A retrospective study was performed to evaluate the effect of such a stepwise approach on the long-term outcome of the disease. A group of 175 children were followed for a mean of 8.4 years (range, 2-16 years) and divided into mild (treated with "as-needed" bronchodilators, usually beta 2-agonists), moderate (treated with sodium cromoglycate), and severe asthmatics (treated with inhaled corticosteroids). Treatment was altered if patients deteriorated or improved. The clinical improvement (as determined by days with symptoms present, emergency room visits, and hospitalizations) of patients being treated with anti-inflammatory agents (sodium cromoglycate or inhaled corticosteroids) was significantly greater than for those receiving bronchodilators. Delay in starting sodium cromoglycate, but not inhaled corticosteroids, had a negative effect on both clinical outcome and pulmonary function. Spirometry showed a significant worsening in the mild group but improvements in the moderate and severe groups. Thus, treatment with anti-inflammatory drugs improves the long-term prognosis and at least partially reverses the natural history of the disease; however, sodium cromoglycate should be started in milder patients than those recommended by the earlier guidelines. The new Global Initiative guidelines have recommended moving the indication for the start of non-steroidal anti-inflammatory drugs from having symptoms on > 3 days per week to having symptoms on > 1 day per week. Considering the fact that inhaled corticosteroids have some side effect even at standard doses, especially in patients with milder asthma, it would appear that a stepwise approach, starting with non-steroidal anti-inflammatory drugs is the most appropriate therapy for patients with mild-to-moderate asthma.