Jeffrey Glassroth, MD
Potential Financial Conflicts of Interest: None disclosed.
Glassroth J. Use of Long-Acting β-Agonists and Inhaled Corticosteroids. Ann Intern Med. 2006;145:710. doi: 10.7326/0003-4819-145-9-200611070-00023
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Published: Ann Intern Med. 2006;145(9):710.
TO THE EDITOR:
Dr. Ernst and colleagues (1) and I agree that inhaled corticosteroids are the appropriate first-line agent for chronic asthma management and that long-acting β-agonists (LABAs) are a valuable next level of treatment for many patients. We seem to disagree on exactly how best to use LABAs. Dr. Ernst and colleagues note that the “greatest benefit from inhaled corticosteroids occurs with low doses” and imply that the need for higher doses will be obviated by early addition of LABAs. In fact, the Gaining Optimal Asthma Control (GOAL) study found that while asthma control could be attained more rapidly and at a lower dose of inhaled corticosteroids by adding LABAs, most study patients were receiving the highest dose of salmeterol–fluticasone or fluticasone by the end of 1 year (2). Martinez (3) subsequently noted that only an additional 10% to 15% of GOAL patients achieved control with intermediate doses of inhaled corticosteroids by adding LABAs. Ernst and colleagues also note that higher doses of inhaled corticosteroid are associated with a “small increase in serious adverse events, such as fractures and cataracts.” Upon examination of their reference on this point, only the use of more than 2000 µg of beclomethasone-equivalent units of inhaled corticosteroids per day for an average of 6 years was associated with an elevated risk for hip fracture (relative risk, 1.61 [compared with age-matched patients in a control group]). Moreover, the log-linear analysis, a measure of dose–response, showed no definite increase (relative risk, 1.03) (4). When all of these data are considered, I believe that the recommendation of ensuring that inhaled corticosteroids have been used to the maximum benefit before considering LABAs is reasonable. At the bottom line, however, we agree on the most important point: Asthma is a serious condition and it should be treated until controlled.
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