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Doubling steroid dose in asthma ‘not enough’

By Lilian Anekwe

Increasing the dose of inhaled steroids at the start of an asthma exacerbation does not reduce the risk of a full blown attack, suggests a Cochrane review.

Researchers looked at five randomised controlled trials of 1250 adults and children in which the strategy of telling patients to increase their inhaled steroid dose at the start of an exacerbation was compared with carrying on with the maintenance dose.

The average usual daily inhaled steroid dose was 555mcg [micrograms] beclomethasone-equivalent and the mean dose following increase was 1520 mcg.

A 15% reduction in the need for rescue oral steroids was seen in the group who increased their inhaled steroid dose but this was not statistically significant.

There was some suggestion the strategy was associated with a doubling of adverse events like pharyngitis and oral thrush but patient numbers in the two relevant trials were too small to make firm conclusions, say the researchers.

Study leader Dr Bradley Quon, a paediatrician at the University of Montreal concluded: ‘To our knowledge, this is the first systematic review and meta-analysis examining the safety and effectiveness of increased inhaled steroid dose at the onset of an asthma exacerbation

‘But it was not associated with a statistically significant difference in the need for rescue oral corticosteroids or other effectiveness outcomes compared to remaining on a stable dose of inhaled steroids.'

The strategy of doubling the dose of inhaled corticosteroids for the early treatment of an asthma exacerbation is included in some action plans.

The current joint guideline published by the British Thoracic Society and the Scottish Intercollegiate Guidelines Network on the management of children and adults in asthma recommends GPs add a long-acting beta agonist to an initial inhaled steroid, then increasing the dose of the inhaled steroid before using oral steroids to control symptoms

The guideline is due to be updated later this year or early 2011. Dr Mike Thomas, a GP in Minchinhampton, Gloucestershire and a member of the BTS/SIGN asthma guideline group told Pulse the review would be looked at by the committee.

He said: ‘Increasing the dose can be effective for some people, but it needs to be a sizeable increase.

‘There's some evidence that increasing the dose of inhaled steroid works but it needs to be a quadruple dose. So if one is going to start pushing up the dose, GPs should think about quadrupling the dose, not just doubling or trebling it.'

Asthma inhaler Strategies for managing exacerbation onset

- Although still recommended in some action plans, doubling the dose of inhaled steroid is of unproven value
- UK guidance states there is some evidence to back a fivefold increase in patients on low maintenance doses (200mcg beclomethasone)
- There is limited evidence for the use of leukotriene antagonists at the onset of symptoms in children
- There is no evidence for parent-initiated oral steroids at the start of an exacerbation

Source BTS/SIGN British guideline on the management of asthma June 209.