Managing asthma: how does taking inhaled corticosteroids only when symptoms get worse compare with daily use?

Key message: intermittent and daily use of inhaled corticosteroids by adults and children with persistent asthma did not significantly differ in the use of rescue oral corticosteroids and the rate of adverse events. Clinicians and patients should carefully weigh up the potential benefits and harms of each treatment option.

People with mild persistent asthma are usually prescribed inhaled corticosteroids (ICS), such as budesonide, to take every day, but many people only take them when their symptoms appear or get worse. This new review from the Cochrane Airways Group looked for evidence from randomized controlled trials (RCTs) comparing these approaches. The authors were interested in how many people had worsening asthma symptoms (exacerbations) needing oral corticosteroids and how many had serious adverse health events. They included six RCTs (four with children, two with adults, 1211 patients) reporting seven comparisons, lasting 12 to 52 weeks, and data were combined. The ICS used was either budesonide or beclomethasone.

What did they find?

  •  No difference between groups in the number of people experiencing one or more exacerbations needing oral corticosteroids
  • No difference between groups in the rate of serious adverse health events
  • Compared with those taking ICS intermittently, people taking ICS daily had slightly better asthma control, but children taking daily ICS grew slightly less
  • Results were consistent for patients of different ages, asthma severity, trial length and types of rescue treatment during exacerbations
  • No firm conclusions can be made as to the superiority of either approach. Confidence intervals (which show the range within which the true treatment effect is likely to lie) were wide, so the rate of exacerbations may be reduced by as much as 17% or increased by as much as 32%

How good is the evidence?

  • This review draws on good quality evidence. All trials were judged to be of high methodological quality and they were generally at low risk of bias
  • The reviewers note that the outstanding collaboration of the authors or funders of six of the seven comparisons allowed them to obtain additional unpublished data and confirm the methodological quality
  • There were few trials available to include in this review and lots of questions remain. For example, the long-term impact of intermittent versus daily ICS on lung growth, airway remodelling (structural changes in the airways caused by long-term unresolved inflammation), bone mineralisation and adrenal function in children, and lung function decline in adults after a year, have yet to be addressed

In the absence of clearer evidence, clinicians and their patients need to consider the potential benefits and harms of each approach to managing persistent asthma. The review contains some helpful suggestions for those designing trials in this area. You can find summaries and podcasts of Cochrane reviews on asthma collected together on the Cochrane Summaries website, from the link below. Here at Evidently Cochrane, we’ll be looking at some new evidence on managing acute asthma later in the week.

Links:

Chauhan BF, Chartrand C, Ducharme FM. Intermittent versus daily inhaled corticosteroids for persistent asthma in children and adults. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD009611. DOI: 10.1002/14651858.CD009611.pub2 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009611.pub2/abstract

Cochrane summary http://summaries.cochrane.org/CD009611/is-taking-inhaled-corticosteroids-only-when-asthma-symptoms-get-worse-as-safe-and-effective-as-taking-inhaled-corticosteroids-every-day See also the collection of Cochrane summaries on Cochrane asthma reviews here http://summaries.cochrane.org/search/site/asthma?solrsort=dm_field_version_published%20desc&f[0]=im_field_stage%3A3

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