Physician-authored summaries and commentary on the most important medical research, provided by the NEJM Group, a division of the Massachusetts Medical Society.
© Massachusetts Medical SocietyApril 2023
In a real-world setting, higher doses actually might worsen asthma outcomes.
Asthma guidelines recommend stepwise increases in inhaled corticosteroid (ICS) doses, based on severity and control. However, higher doses of ICS are associated with adverse effects, and whether they actually improve asthma outcomes is unclear.
In a historical UK cohort study that involved 70,000 adolescents and adults with asthma, researchers examined the effect of stepping up from medium- to high-dose ICS. In an analysis adjusted for asthma severity, time to first exacerbation actually was significantly shorter in patients who stepped up to high-dose ICS than in those who remained on medium-dose ICS (2.0 vs 2.7 years). Overall exacerbations and need for antibiotic courses occurred significantly more frequently in the step-up group; these differences were seen regardless of eosinophilia presence or adherence to medication.
Comment: It is unclear why higher ICS doses were associated with worse asthma outcomes. Two potential explanations are residual confounding and greater risk for respiratory infection with higher doses. Regardless of the explanation, I believe that instead of increasing ICS doses in patients with uncontrolled asthma, we first should look at addressing factors such as adherence and inhaler technique, obesity, deconditioning and anxiety. Then, rather than using a higher daily dose of ICS, we should use maintenance and reliever dosing with ICS/formoterol so that patients only get higher ICS doses when they need them (JAMA 2020; 324: 2301-2317). Finally, editorialists discuss two other relevant issues that favour lower ICS doses: 80 to 90% of ICS efficacy is achieved with low doses, and medium-to-high doses are associated with side effects comparable to those of 5 mg of prednisone daily.
David J. Amrol, MD
Associate Professor of Clinical Internal Medicine, Director of the Division of Allergy and Immunology, University of South Carolina School of Medicine, Columbia, USA.
Pavord ID, et al. Effect of stepping up to high-dose inhaled corticosteroids in patients with asthma: UK database study. J Allergy Clin Immunol Pract 2023; 11: 532-543.
Beasley R, Kankaanranta H. Inhaled corticosteroids in asthma: when less is more. J Allergy Clin Immunol Pract 2023; 11: 544-545.
This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Hospital Medicine