Asthma

Quadruple ICS reduces severe asthma exacerbations


A self managed four-fold increase in the dose of inhaled corticosteroids reduces severe asthma exacerbations, a late breaking trial at ERS Congress reports.

According to the lead author Professor Tim Harrison, a respiratory physician from the University of Nottingham in the UK, the findings are likely to find their way into asthma guidelines in the very near future.

The trial randomised almost 2,000 adults with asthma to a ‘usual care’ group who increased their bronchodilator medication when they experienced asthma symptoms or to a ‘modified group’ who were also asked to quadruple their inhaled corticosteroid dose.

At one year the severe asthma exacerbation rate was 0.79 v 0.65 (per person year) in the usual care and modified care groups respectively, with an adjusted hazard ratio of 0.81 (95% CI 0.71 to 0.92, p=0.002).

Speaking to the limbic Professor Harrison conceded that a 20 percent reduced risk of an exacerbation didn’t sound enormous but when it was put into the context of other treatments you could add you started to see the significance.

“If we were adding in a biologic we might expect to see a reduction in exacerbations of 40 percent,” he explained.

“This was a very real-life study, people just took the self management plan away and got on with it so I think if it had been a closely monitored RCT the effect would have been bigger,” he added.

This line of research is not new for Professor Harrison. In 2004 he published a paper in The Lancet that found doubling the dose of an ICS didn’t have an effect on the number of exacerbations people experienced.

In 2009 they published a paper in the Blue Journal that studied the effects of a four-fold increase but the trial did not meet its endpoint because it wasn’t adequately powered.

The results, however, did suggest that a four-fold increase in ICS was effective in reducing exacerbations and Professor Harrison and colleagues decided to pursue their line of inquiry.

“Our results [of the current study] show that if patients want to do something before they get really bad, the best evidence is to quadruple their dose of ICS as quickly as possible,” Professor Harrison said.

He has already been approached by several international asthma organisations who want the findings in their next guidelines review.

But the approach cannot be included in asthma guidelines until the paper is published in full, explains Professor Harrison.

He is submitting to one of the leading journals in the next few weeks.

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