Jaspal Singh, MD, MHS, MHA, FCCP
In patients with asthma controlled with inhaled corticosteroids (ICSs) plus a long-acting β2-agonist (LABA), what are the effects of discontinuing LABAs?
Included studies compared LABA discontinuation and unchanged ICS dose with continued use and unchanged dose of both LABAs and ICSs in patients ≥ 4 years of age who had asthma and were receiving combined LABA (salmeterol or formoterol fumarate dihydrate) and ICS therapy twice daily for ≥ 3 months, and had well-controlled asthma for ≥ 3 months before LABA discontinuation. Outcomes included emergency department visit or unscheduled consultation for asthma, use of systemic corticosteroids, withdrawal from treatment due to lack of efficacy or loss of asthma control, serious adverse events, quality of life (Asthma Quality of Life Questionnaire), asthma control (Asthma Control Questionnaire), symptom-free days, rescue bronchodilator use, death, and hospitalization.
MEDLINE, EMBASE/Excerpta Medica, Cochrane Library, ClinicalTrials.gov, Database of Abstracts of Reviews of Effects, and National Health Service Economic Evaluation Database (all to Aug 2010); manufacturer trials registries; reviews; and reference lists were searched for randomized controlled trials (RCTs). Manufacturers of salmeterol and formoterol were contacted. 5 RCTs (n = 1352, mean age 38 to 47 y, 49% to 65% women) met selection criteria. All studies included older adolescents (≥ 15 y) or adults, and ICSs and LABAs were delivered in a single inhaler. All studies had low risk for bias based on randomization, allocation concealment, blinding, and intention-to-treat analysis. Risk for bias was high for loss to follow-up (12% to 38% discontinued treatment and were excluded from some analyses). All studies were funded by study drug manufacturers.
The main results are in the Table. No deaths or hospitalizations occurred in either group.
In patients with asthma controlled with inhaled corticosteroids plus a long-acting β2-agonist (LABA), discontinuation of LABAs worsens asthma control and quality of life.
LABA discontinuation (D/C) vs continuation (C) in patients with asthma controlled with combined ICS and LABA therapy*
*ACQ = Asthma Control Questionnaire; AQLQ = Asthma Quality of Life Questionnaire; ICS = inhaled corticosteroid; LABA = long-acting β2-agonist; NS = not significant; other abbreviations defined in Glossary. Weighted event rates, RRI, RRR, NNH, NNT, and CI calculated from control event rates and risk ratios in article using a random-effects model.
†Emergency department visit or unscheduled consultation for asthma.
‡Withdrawal from treatment due to lack of efficacy or loss of asthma control.
§Differences in scores favor LABA continuation group.
||Score range 1 to 7, higher scores = better quality of life.
¶Score range 0 to 6, lower scores = better asthma control.
Jaspal Singh. Review: In asthma controlled with ICSs plus LABAs, stopping LABAs increases asthma impairment. Ann Intern Med. 2012;157:JC6–4. doi: 10.7326/0003-4819-157-12-201212180-02004
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Published: Ann Intern Med. 2012;157(12):JC6-4.
Asthma, Pulmonary/Critical Care.
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