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Very high dose inhaled corticosteroids: panacea or poison?
  1. G Russell
  1. Correspondence to:
    Dr G Russell
    Department of Child Health, University of Aberdeen, Royal Aberdeen Children’s Hospital, Aberdeen AB25 2ZG, UK; libra{at}

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Perspective on the paper by Paton et al (see page 808)

Only the older readers of Archives will remember a time when inhaled corticosteroid therapy (ICT) was not the mainstay of asthma treatment. In the 1960s asthma was an unpredictable and more or less untreatable disease, and the diagnosis was made with reluctance by doctors and accepted with dismay by parents. The therapeutic options were limited. For acute relief, isoprenaline (isoproterenol) was given by pressurised metered dose inhaler, but its effects lasted for only a few minutes, and it fell into disrepute after only a decade, when its use appeared to be associated with increased mortality.1 In hospital, subcutaneous adrenaline backed up by oral or intravenous corticosteroids was the mainstay of therapy. Interval management was mainly with bronchodilators such as ephedrine, theophylline, and the belladonna alkaloids, and compound preparations such as Tedral, an unlikely mixture of theophylline, ephedrine, and phenobarbital, were popular. These drugs were of undoubted benefit, but disappointingly large numbers of children required maintenance therapy with oral corticosteroids.

The asthma clinic at the Children’s Hospital in Aberdeen was established primarily to manage children who were on long term systemic corticosteroids for their asthma. My brief was to ensure that all other therapeutic possibilities were explored so as to keep the dose of corticosteroids to a minimum. Other than introducing the use of ACTH to protect growth,2 I doubt if my ministrations made much difference until the arrival in rapid succession of salbutamol,3 sodium cromoglycate (cromolyn),4 and finally beclomethasone,5 which together transformed the management of asthma. As can be seen from fig 1, these new drugs rapidly made the original raison d’être of the clinic an irrelevancy, and I became a committed devotee of ICT.

Figure 1

 Number of patients on oral corticosteroid …

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  • Competing interests: I have had no dealings with the drug industry in the past five years, but prior to that I received hospitality and fees from the manufacturers of beclomethasone, budesonide, and fluticasone. Any monies received were paid into the Respiratory Clinic Fund, used to support the activities of the Asthma Clinic at the Royal Aberdeen Children’s Hospital.

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