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Saskatoon, Saskatchewan, Canada
Correspondence to: Donald W. Cockcroft, MD, FCCP, Division of Respiratory Medicine, 103 Hospital Dr, Saskatoon, Saskatchewan, S7N OW8 Canada; e-mail: cockcroft{at}sask.usask.com
To the Editor:
We read with interest the provocative statement in an editorial in CHEST (July 2000) by Dr. Speir: "...I remain convinced that regularly scheduled inhaled bronchodilators are the mainstay of maintenance therapy in all but the very mildest of asthmatic patients... ."1
While we agree with the other excellent points made by Dr. Speir, we cannot support the recommendation that regularly scheduled inhaled bronchodilators are the mainstay of maintenance asthma therapy. All national and international asthma treatment guidelines agree that the most commonly used inhaled bronchodilators, short-acting inhaled ß2-agonists, should be used exclusively on demand. Recommendations are that asthma should be controlled with anti-inflammatory therapeutic strategies so that the on-demand requirement for short-acting bronchodilators be infrequent and, in most cases, arbitrarily established at a level of two or three times per week or less. Maintenance treatment with long-acting inhaled ß2-agonists is recommended only when asthma control cannot be achieved with optimal (moderate) doses of inhaled corticosteroids.
These recommendations are supported by several controlled clinical trials which demonstrate that, compared to placebo, regularly scheduled short-acting inhaled ß2-agonists produce mild clinically relevant worsening asthma control,2 or subtle statistically significant but clinically irrelevant changes favoring worsened asthma control.3 Importantly, none of these studies demonstrates any advantage for the regular use of short-acting inhaled ß2-agonists.2 3 4 In an editorial comment5 regarding the most recent study,4 Dr. Sears has summarized, "...short acting inhaled ß2-agonists should be used only as needed for symptom relief and not for maintenance therapy in asthma."
We agree that the management of severe and life-threatening asthmatic crisis requires intensive and continuous bronchodilator therapy, which may occasionally be life-saving. We disagree that this approach requires continuation into the maintenance therapy where, at best, it has been demonstrated to be no more effective than placebo therapy, and at worst may lead to suboptimal asthma control by several possible mechanisms, the most important of which is probably overreliance with subsequent noncompliance with more appropriate anti-inflammatory maintenance therapy, particularly inhaled corticosteroids.
References
Augusta, GA
Correspondence to: William A. Speir Jr, MD, FCCP, Medical College of Georgia Hospital, 1120 15th St, Room BBR 5513, Augusta, GA 30912-0004; e-mail: bandm.speir{at}mindspring.com
To the Editor:
I appreciate the comments of Drs. Boulet and Cockcroft. Their views are well known, enjoy wide support, and I certainly respect their opinion. However, I wonder if their reading of the editorial in CHEST (July 2000)1 is not la critica sospettosa?
The point of contention hinges on the sentence, "...I remain convinced that regularly scheduled inhaled bronchodilators are the mainstay of maintenance therapy in all but the mildest of asthmatic patients (‘the open airway approach’)."1
I am (and was) quite familiar with the national and international asthma treatment guidelines. Guidelines are useful, but they are inherently arbitrary and should never be "codified." As I pointed out, morbidity and mortality of asthma is increasing, the severity of the disease is frequently underestimated, and patients admitted to hospitals and ICUs are invariably undertreated. Even a satisfactory definition of asthma has proven difficult. Certainly, the majority of patients with mild asthma may be managed with inhaled steroids and only occasional inhaled bronchodilators. On the other hand, many "asymptomatic" asthmatics have wheezes on auscultation and significantly reduced expiratory flow rates. These "mild" asthmatics benefit from addition of a long-acting ß2-agonist as part of a comprehensive maintenance program including inhaled steroids. In addition, the recent meta-analysis by Shrewsbury2 would seem to suggest that the use of long-acting ß2-agonists in maintenance therapy just might be beneficial.
Perhaps Drs. Boulet, Cockcroft, and I are much closer in our thinking and approach to the use of inhaled bronchodilators as part of a comprehensive management program than their letter would seem to indicate; perhaps not. For some reason, they have a fixation on the use of short-acting ß2-agonists maintenance therapy. I don’t think many pulmonary/critical care physicians use that approach now that effective long-acting ß2-agonists are available.
If indeed, as Drs. Boulet and Cockcroft state, that the use of short-acting ß2-agonists "...may lead to suboptimal asthma control by several mechanisms, the most important of which is probably overreliance with subsequent noncompliance with more appropriate anti-inflammatory maintenance therapy, particularly inhaled corticosteroids," is it possible that such patients are undertreated and might benefit from the addition of a long-acting ß2-agonists?
I don’t have any answers. Asthma is a strange disease. There is much left to be learned. As physicians, we must guard against becoming algorithmic automatons, and we must continue to treat individual patients, national and international guidelines not withstanding.
References
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