Literature review highlights options for self-management of asthma exacerbations

An extensive literature review undertaken by the Woolcock Institute of Medical Research has examined the pharmacological strategies for self-management of asthma exacerbations in adults, including those using inhaled corticosteroid/long-acting 2-agonist (ICS/LABA) therapy.

The review provides evidence-based recommendations on the best way to use oral corticosteroids (OCS) to treat severe exacerbations and questions whether studies support the common practice of doubling inhaled corticosteroids (ICS) doses as a form of treatment. It also looks at whether increasing ICS to high doses is an alternative to OCS, as well as the effects of increasing the dose of combination therapy during exacerbations.

Use of inhaled ICS/LABA for maintenance and relief, and the effectiveness of short- acting 2-agonist (SABAs) in the management of exacerbations have also been addressed.

Dr Helen Reddel of the Woolcock Institute and Dr David Barnes from Royal Prince Alfred Hospital, authors of the narrative review which is published in the latest issue of European Respiratory Journal, said the project was undertaken in a bid to help clinicians determine the specific therapeutic instructions which should be included in written asthma action plans.

Dr Reddel explains most of the advice in current international guidelines about how to manage exacerbations was published prior to the introduction of combination therapy.

"However recent years have seen an increase in the proportion of patients being prescribed combination inhaled corticosteroid/long-acting 2-agonist therapy in one inhaler device for the management of persistent asthma," she said.

"The review recognises the importance of written action plans as a beneficial part of an integrated program to substantially improve health outcomes for people with asthma. Our aim was to determine what recommendations should be included in these plans and to make sure they encompass patients taking combination therapy," she said.

A Medline search was used to review relevant papers covering the period 1990-2004. Key findings include:

  • Oral corticosteroids are well established in clinical practice and clinical trials for the treatment of severe exacerbations, including during treatment with combination therapy. Evidence supports 7-10 days treatment with no need to taper except to reduce side effects.
  • Three studies have shown that doubling the dose of ICS is not effective for treatment of exacerbations.
  • Several studies have shown benefit from high dose ICS (2400-4000g beclomethasone equivalent) for 1-2 weeks. This may be achieved by adding a high-dose ICS inhaler to maintenance ICS or ICS/LABA therapy.
  • There is inconclusive evidence about acutely increasing the dose of maintenance budesonide/formoterol after onset of an exacerbation, and no studies of this approach with fluticasone/salmeterol.
  • Short-acting 2-agonists are still effective in producing bronchodilation during combination therapy; however a higher dose may be required. Patients who are taking combination therapy should be reminded that they may useshort-acting 2-agonists for relief of symptoms.

Dr Reddel points outs there is a need for further studies to clarify remaining issues about self-management of asthma exacerbations, particularly with regard to side-effects of treatment and patient acceptability.

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The research was undertaken with the assistance of GlaxoSmithKline. A full outline of the review's findings will be published in the July issue of ERJ.

For further information contact Lucy:
Lucy Williams
Woolcock Institute of Medical Research
+61 403 753 028
Website: www.woolcock.org.au
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