PRN steroids are as good as—or better than—daily dosing for asthma

Journal of Family Practice, August, 2007

* Clinical question

Must inhaled corticosteroids be taken daily by patients with mild persistent asthma?

* Bottom line

No. For patients with mild persistent asthma, symptoms and exacerbations were controlled just as well using a combination of beclomethasone 250 mcg plus albutero1100 mcg as needed instead of daily. This approach reduced the amount of steroids given, and may result in better adherence as well.

Level of evidence

1b: Individual randomized controlled trial (with narrow confidence interval)

Study design

Randomized controlled trial (double-blinded)

Funding

Industry

Allocation

Concealed

Setting

Outpatient (specialty)

Synopsis

For years we've been telling our patients with mild persistent asthma that they must take their corticosteroid inhaler daily, not as needed.

Is that really true?

In this study, 510 patients were given a 4-week course of beclomethasone dipropionate 250 mcg twice daily plus an albuterol inhaler to be used as needed. Those with good asthma control while using this regimen were then randomized to 1 of 4 groups: (1) continued beclomethasone 250 mcg twice daily plus albuterol as needed, (2) beclomethasone 250 mcg plus albuterol 100 mcg twice daily plus albuterol as needed, (3) albuterol as needed only, and (4) beclomethasone 250 mcg plus albuterol 100 mcg to be used as needed only. Patients received placebo inhalers to maintain masking, and outcomes were assessed by researchers masked to treatment assignment.

Of the 466 who started, 393 completed the 6-month study; dropouts were similar among the groups. Half the patients were women; mean age was 39 years.

Outcomes. A variety of physiologic measures of lung function found that the as-needed combination of steroid and beta-agonist:

* was more effective than albuterol alone

* was as effective as the traditional combination of daily steroid and as-needed beta-agonist.

The as-needed combination course resulted in:

* fewer exacerbations than the albuterol-only group (0.74 per year vs 1.63 per year; P<.001)

* number of exacerbations similar to that of the group taking beclomethasone daily and as-needed albuterol

* a total steroid dose 60 mg less than that of the daily-steroid group (18 mg vs 78 mg)

* a percentage of symptom-free days similar to that of the group taking medications daily.

FAST TRACK

As-needed steroids for mild asthma controlled symptoms as well as daily dosing, and may improve adherence

Papi A, Canonica GW, Maestrelli P, et al, for the BEST Study Group. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med 2007; 356:2040-2052.