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I read with interest your article 'What's new in asthma and allergic rhinitis' (Clinical, September 20), in particular the review of guideline-based asthma control.

Dr Glenis Scadding makes a valid point that the Gaining Optimal Asthma Control study of the salmeterol/fluticasone combination demonstrates the concept of 'total control' was only achieved in less than half of the mildest group of patients.

Far from being guideline-based, this limited control was achieved using questionably high doses of inhaled corticosteroid.

It is important to recognise that severity of asthma symptoms changes on a daily, weekly and seasonal basis and in response to viral infections and other factors. There are benefits of an approach where dosing is stepped up and down according to symptoms.

A recent study where the dose of a combination of budesonide/formoterol was adjusted in response to symptoms, reported similar levels of asthma control as salmeterol/ fluticasone, but using less medication and with fewer exacerbations.

Reducing the treatment dose once control is achieved is strongly recommended by the BTS/SIGN guidelines for asthma management. In the GOAL study it appears 68 per cent of those achieving control were on the highest dose of fluticasone, ie 500µg bd (equivalent to 2000µg beclometasone per day) which exceeds the amount recommended in the guidelines by 1200µg beclometasone per day. We should be as wary of overtreating our patients as we are of undertreating them.

Dr Dermot Ryan

Loughborough

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