Quadrupling steroid dose reduces risk of asthma exacerbations

Temporarily increasing the inhaled glucocorticoid dose at the first sign of deteriorating asthma control significantly reduces the incidence of severe exacerbations, new research has shown.

Temporarily quadrupling the dosage of inhaled corticosteroids cuts the rate of serious asthma attacks by almost a fifth. | iStock
Temporarily quadrupling the dosage of inhaled corticosteroids cuts the rate of serious asthma attacks by almost a fifth. | iStock

A team led by researchers at the University of Nottingham has found that a short-term four-fold increase in the dose of inhaled glucocorticoids cuts the risk of severe asthma exacerbations by almost 20%.

Exacerbations

In an unblinded study published in the New England Journal of Medicine, Professor Tim Harrison and colleagues recruited adults and adolescents with asthma who were receiving inhaled glucocorticoids, with or without add-on therapy, and who had had at least one exacerbation in the previous 12 months.

They randomised 1922 participants to a self-management plan that included a four-fold increased dose of inhaled glucocorticoids or the same plan without increased dose, over a period of 12 months.

The primary outcome was the time to first severe asthma exacerbation, defined as treatment with systemic glucocorticoids or an unscheduled healthcare consultation for asthma.

In the year after randomisation, the proportion of participants who experienced a severe asthma exacerbation was 45% in the quadrupling group compared with 52% in the control group, giving an adjusted hazard ratio for the time to first severe exacerbation of 0.81 (95% CI 0.71-0.92; p=0.002).

In addition, patients in the quadrupling group were less likely to require systemic glucocorticoids (33% vs 40%) or unscheduled healthcare consultations (41% vs 47%). There were three hospitalisations for severe asthma in the quadrupling group, compared with 18 in the non-quadrupling group.

However, adverse events were more common in the quadrupling group, with higher rates of oral candidiasis and dysphonia.

Self-management plan

'Our study shows that patients can reduce the risk of a severe asthma attack by following a self-management plan which includes a temporary four-fold increase in their preventer medication when their asthma is deteriorating,' said Professor Harrison. 'This means less need for oral steroids such as prednisolone, less admissions to hospital with severe asthma and hopefully fewer deaths from asthma.'

The authors estimate the number of patients needed to be provided with such a self-management plan in order to prevent one severe asthma exacerbation is 15 (95% CI 9-43).

Previous research indicated that doubling the dose of inhaled corticosteroids around the time of an exacerbation was not effective at preventing severe asthma attacks, leading Harrison and colleagues to hypothesise that a quadruple dose may be required.

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