Saturday, September 7, 2013

Intermittent Use of Inhaled Steroids for Mild Asthma

For decades now, guidelines for asthma care have recommended that persons with persistent asthma should take daily anti-inflammatory medication, preferably an inhaled steroid, to lessen their symptoms of asthma and reduce the frequency of flare-ups of their disease (asthma “attacks”).  At the same time, it has been suggested that persons who have very mild disease and few symptoms (“intermittent asthma”) can use their quick-relief bronchodilator as needed and need no other medication for their asthma.  Inhaled steroids have not been recommended for persons with mild and intermittent asthma because: 1) infrequent symptoms do not seem to warrant daily medication, and 2) evidence indicates that long-term use of inhaled steroids does not improve lung function over time or affect long-term outcomes in asthma.

Panels of experts write the asthma guidelines based on their experience and available scientific information.  (The guidelines are not divinely inspired or carved in stone tablets!)  Asked to define “persistent asthma,” the experts reached the following consensus: anyone who has two days or more of asthma symptoms each week or wakes up two or more times with asthma symptoms each month or has lung function that is below normal or has had two or more attacks of asthma (requiring oral steroids) in the past year.  Taken as a whole, patients with persistent asthma who are treated with regular (daily) inhaled steroids have fewer symptoms of their asthma, less need for their “rescue” bronchodilator, better lung function, fewer asthma attacks, and an overall improved sense of well-being. 

But a fair question – and one that has now been addressed by recent clinical research – is exactly where one should draw the line between “intermittent” and “persistent” asthma.  Did the experts get it right, or are there patients with persistent (as defined above) but mild asthma who do not in fact need to take an anti-inflammatory medication daily for relief of symptoms and prevention of asthmatic attacks?  If you have mild persistent asthma and your symptoms are sufficiently few (more than two days out of the week but less than every day), prior asthma attacks have been sufficiently rare, and breathing tests are for the most part normal, might you take inhaled steroids only during periods when your asthma is troublesome but stop them during times when your asthma is no longer bothering you?  It is very likely that many patients with asthma have been following this practice for years – because daily medication use can be onerous – but is it safe and advisable?

Two studies – one in adults [Boushey et al., New England Journal of Medicine 2005; 352:1519] and one in young children [Zeiger et al., New England Journal of Medicine 2011; 365:1990]  – have indicated that the strategy of using inhaled steroids intermittently, only during periods of increased symptoms, is indeed safe for persons with mild persistent asthma.  These studies found that among persons with mild persistent asthma there was no difference in the frequency of asthma attacks, including severe or dangerous attacks, and very little overall difference in sense of well-being whether they used their inhaled steroids every day vs. used them only when symptoms became troublesome … as long as everyone had a plan regarding how to deal with an asthma attack. 

Let’s be specific.  Based on these recent studies, if your asthma has been mild, your medical provider might prescribe for you an albuterol (ProAir, Proventil, or Ventolin) or levalbuterol (Xopenex) inhaler to use whenever you need it.  If you find yourself using your quick-relief bronchodilator a lot, or if you feel congested at the start of a “cold,” or if you are visiting your in-laws who own a cat to which you are allergic, you would begin your steroid inhaler, such as fluticasone (Flovent), budesonide (Pulmicort), beclomethasone (Qvar), mometasone (Asmanex), or ciclesonide (Alvesco).  You would probably take at least four inhalations morning and night every day for approximately ten days, and then when you felt better, didn’t need your rescue bronchodilator so often, had gotten over the cold, or were no longer exposed to the pet cat, stop your steroid inhaler.  And you would be prepared with the knowledge that if your symptoms worsened despite taking the inhaled steroid, you would need to begin oral steroids (e.g., prednisone or Medrol) and be in contact with your healthcare provider.

Two important caveats before one puts this approach into practice.  First, it is not intended for persons with more severe forms of asthma.  Our emergency departments routinely treat persons with asthma who had been doing well until they stopped taking their preventive asthma medication (their inhaled steroids), thinking that they no longer needed them, and then developed severe asthma symptoms.  In persons with moderate and severe persistent asthma, evidence is unequivocal that reducing the dose and then stopping inhaled steroids is associated with more asthma attacks and worse asthma control.  Second, intermittent use of inhaled steroids does not mean “as needed” or “p.r.n.”  For this new strategy to work, the inhaled steroids need to be taken not here and there trying to relieve symptoms but every day, usually twice a day, for a period of 1-2 weeks or more.  Intermittent use of inhaled steroids refers to regular, daily administration, but for a limited period of time rather than year-round indefinitely.

In the future, another group of national and international asthma experts will write an updated set of asthma guidelines and render its opinion regarding this approach to asthma care.  In the meantime, our opinion is that this is a safe and reasonable way to treat mild asthma.  It is not appropriate for persons whose asthma is more severe, and its implementation requires careful explanation and reinforcement such that everyone is clear as to when to begin the inhaled steroids, how to use them and for how long, and what to do if asthma fails to improve as expected.


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