Chest
Volume 102, Issue 6, December 1992, Pages 1709-1715
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Clinical Investigations
Increased Inhaled Bronchodilator vs Increased Inhaled Corticosteroid in the Control of Moderate Asthma

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Undertreatment of chronic asthma may reflect uncertainty as to how it may be best controlled. We compared the effects of increased inhaled corticosteroid vs regular inhaled bronchodilator in 32 adult asthmatics. During three 16-week treatment periods, comprising baseline inhaled corticosteroid (mean 505 µg daily) and on-demand β-agonist, baseline inhaled corticosteroid and increased (regularly scheduled four times daily) β-agonist, and increased inhaled corticosteroid (mean 1478 µg daily) and on-demand 0-agonist, subjects recorded symptoms, morning and evening peak flow, and additional medication. Of 25 subjects whose control differed significantly between treatments with baseline vs increased corticosteroid, 22 (88 percent) favored the increased dosage (p<0.001). Of 28 subjects whose control differed between treatments with regular β-agonist vs increased corticosteroid, 24 (86 percent) were better controlled with increased inhaled corticosteroid and were worse with regular β-agonist (p<0.001). Only one quarter the number of exacerbations were experienced during treatment with increased inhaled corticosteroid. Upper airway adverse effects were minor and easily controlled. Hence, asthma with persistent symptoms was better controlled by increased inhaled corticosteroid therapy than by increased use of inhaled β-agonist.

Section snippets

Methods

Immediately on completion of a randomized double-blind crossover study comparing regularly scheduled with “on-demand” inhaled β-agonist treatment,9 subjects were offered the opportunity to participate in a further study to determine the effect of increasing the daily dosage of inhaled corticosteroid on control of asthma. In the original double-blind study, subjects with mild or moderate asthma inhaled either dry powder fenoterol 400 µg or placebo four times daily for 24 weeks, then crossed over

Results

Of the 34 subjects participating in this study, 32 provided complete data for analysis. Two subjects lost 37 and 54 days, respectively, of their diaries, and so were excluded. Twenty-six of the 32 subjects had used inhaled corticosteroids during periods A and B, in doses ranging from 150 to 2,000 µg daily, while six subjects had not previously used inhaled corticosteroids in any dosage. The 32 subjects completing this study were representative of the 64 subjects in the initial study of

Discussion

This study has demonstrated that increasing the dose of inhaled corticosteroid, in conjunction with use of an inhaled β-agonist only on demand, provided a substantially greater beneficial effect on control of asthma than increasing inhaled β-agonist by regular scheduled doses of a potent β-sympathomimetic agent four times daily. Symptoms were suppressed or eliminated, especially at night, morning PEFR increased, and the need for β-agonist was reduced substantially. These findings extend other

Acknowledgments

The authors thank the subjects for their willingness to participate in this lengthy study, and Marilyn Lucas, Denise Yates, and Qingqing Li for their technical assistance.

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    The study was funded by the Medical Research Council of New Zealand, with supplementary funding by Astra (Pharmaco) NZ Ltd and Fisons (NZ).

    Manuscript received February 13; revision accepted May 18.

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