Adults With Mild Asthma Can Limit Drugs, Study Says
About 4 million adult Americans with a mild form of asthma may not need to take daily steroid doses, but instead can use the drug only as needed to control symptoms, says a new study supported by the National Institutes of Health.
The change would make drug use more convenient, minimize side effects from the powerful drugs and possibly save the nation as much as $2 billion per year, the study concludes.
Its results do not apply to the 10 million adults with more severe forms of the disease, but “for some adults with long-standing mild persistent asthma, choosing not to take daily medications might be OK,” said Dr. Elliott Israel of Brigham and Women’s Hospital in Boston, the co-leader of the study.
Israel noted that many such patients were routinely skipping the medicine. About 30% of prescriptions for the daily steroids are refilled, apparently because patients don’t think it makes them feel better. The findings, published today in the New England Journal of Medicine, appear to validate that belief, he said.
The results are likely to change clinical practices in the management of asthma, Dr. Leonardo M. Fabbri of the Universita degli Studi di Modena e Reggio Emilia-Policlinico di Modena in Italy wrote in an editorial accompanying the report. Intermittent dosing, he said, “complies with the philosophy of achieving and maintaining control of asthma with the least amount of medicine.”
The study “shows that physicians can be less dogmatic in treating mild asthma,” not insisting that patients follow a carefully prescribed regimen, added Dr. Jonathan Field, director of the New York University Allergy and Asthma Clinic, who was not involved in the study.
Asthma is considered mild and persistent when individuals have acute symptoms such as wheezing, coughing or chest tightness two to five times a week or are awakened by asthma more than twice a month. Perhaps a third of the 14 million U.S. adults and 6 million children with asthma have this form. Children were not included in the study.
Treatment guidelines published in 1997 indicated that patients with this form should use an inhaled steroid called budesonide (marketed as Rhinocort) daily to control their disease and an inhaled bronchodilator called albuterol to treat symptoms as they occurred. An alterative is daily use of another drug, zafirlukast (marketed as Accolate).
Those guidelines were based on earlier studies that suggested daily use of the drugs prevented long-term damage to the lungs. But closer analysis of the studies indicated that many of the patients did not have mild persistent asthma, said Dr. Homer A. Boushey of UC San Francisco, the study’s other co-leader.
In the new trial, 225 adults with confirmed mild persistent asthma were given either daily budesonide, zafirlukast or a placebo, and allowed to use a bronchodilator as needed. All patients were also given budesonide and taught how to administer a 10-day course of the drug if they suffered an outbreak of symptoms.
At the end of the year, “all three groups were far more alike than they were different,” Boushey said. Their lung functions were similar, they had about the same frequency of severe attacks and they all showed little or no evidence of lung damage.
Those taking budesonide reported about 24 more symptom-free days per year, but they did not rate their quality of life higher than those receiving zafirlukast or the placebo. “That’s not too surprising,” Boushey said, “because the symptoms of mild persistent asthma are, by definition, mild.”
Although the findings need to be confirmed by a larger study, he said, “the guidelines should back off a little bit. Clearly, we’ve set the bar too high for defining what people need every day.”
