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Adding extra puffs of steroid inhaler when a short-acting beta-agonist is needed reduces exacerbations in moderate to severe asthma
Clinical Question
In Black and Latinx adults with moderate to severe asthma, does adding an extra puff of glucocorticoid inhaler whenever a short-acting beta-agonist inhaler is needed reduce exacerbations compared with usual care?
Bottom line
Instead of telling patients with moderate to severe asthma to just use their SABA when they have symptoms, you should have them accompany the SABA with a puff of their corticosteroid. You may have to customize the ratio of puffs for each patient. For example, if someone uses a 160-mcg beclomethasone inhaler, they should only use 1 puff for every 2 puffs of SABA. 1b-
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Government
Setting: Outpatient (any)
Synopsis
These researchers recruited 1201 Black and Latinx adults with moderate to severe, poorly controlled asthma who were already prescribed an inhaled corticosteroid. The mean age of participants was 48 years, 85% were women, and 72% had at least one asthma exacerbation in the previous year. Exacerbations were defined as an emergency department or urgent care visit, hospitalization, or a course of systemic glucocorticoids. All patients continued usual care, which was a daily inhaled glucocorticoid with (72%) or without (28%) a long-acting beta-agonist, supplemented by as-needed use of a short-acting beta-agonist (SABA) "reliever" inhaler. Those patients randomized to the intervention group were instructed to also use additional glucocorticoid inhaler puffs whenever they used their reliever (beclomethasone 80 mcg, 1 puff per each puff of their reliever, or 5 puffs if using a nebulizer as the reliever). Groups were balanced at the beginning the unmasked study, allocation was concealed, and analysis was by intention to treat. After a median of 14.9 months, the annual rate of exacerbations was lower in the intervention group (0.69 vs 0.82; hazard ratio 0.85; 95% CI 0.72 - 0.999). That is approximately 1 fewer exacerbation for every 8 patients who received usual care plus the intervention compared with usual care alone. Asthma control scores increased by 1 to 2 points more in the intervention group, which is less than the minimal clinically important difference of 3 points for this score. Participants in the intervention group used approximately one more steroid inhaler per year than did patients in the usual care group. There was no difference in serious adverse events between groups.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
Mixedmessaging
Guidelines out there suggest instead symbicort for reliever instead of adding steroid inhaler to SABA. I have asked at educational rounds whether other ICS and LABA could be used as a means of reducing costs and advised to stick to Symbicort as that where the eviidence is. This study mainly tells me that any steroid would likely work in titrating the steroid inhaler to the severity. I would prefer a LABA with rapid reliever effect than a SABA but if affordability is an issue Looks like SABA with steroid dose titrated to SABA frequency will work.
Inhalers and asthma
Good
No
No comment
Higher frequency of inhalable steroids and acute episodes of
This element of increasing the steroid inhalation reducing the need for increased dose of SBA is already in clinical debates in several countries but a solid information at the end of valuable study would make it clear and scientific. But one should always bear in mind the immune status of the patient so as to carefully follow them up for any probable fungal pneumonitis.