David J. Amrol, MD reviewing Reddel HK et al. Lancet 2016 Nov 29. Papi A and Fabbri LM. Lancet 2016 Nov 29.

Recommending inhaled steroids routinely would be premature, although a small proportion of these patients might benefit.

Current U.S. guidelines recommend inhaled steroids (ICS) as first-line treatment for patients with persistent asthma; however, for patients with normal lung function, rare exacerbations, and symptoms fewer than thrice weekly, only as-needed, short-acting bronchodilators are recommended. This approach is universally accepted, but it is not based on clinical evidence. In the START trial, researchers examined the effectiveness of low-dose budesonide within 2 years of diagnosis in adults and children with mild asthma (NEJM JW Pediatr Adolesc Med Jun 2003 and Lancet 2003; 361:1071).

In this post hoc analysis of START data, researchers evaluated 4098 patients with symptoms fewer than 3 days weekly who were randomized to daily budesonide (400 μg in adults; 200 μg in children) or placebo. Budesonide recipients had fewer severe asthma-related events that required emergency treatment and systemic steroids (9 fewer per year per 1000 patients), fewer courses of oral steroids (90 fewer per year per 1000 patients), and ≈1% less loss of post-bronchodilator forced expiratory volume in 1 second (FEV1) after 3 years. Symptom scores improved minimally with budesonide; mortality was similar between groups.

CITATION(S):

Reddel HK et al. Should recommendations about starting inhaled corticosteroid treatment for mild asthma be based on symptom frequency: A post-hoc efficacy analysis of the START study. Lancet 2016 Nov 29; [e-pub]. 

Papi A and Fabbri LM.Management of patients with early mild asthma and infrequent symptoms. Lancet 2016 Nov 29; [e-pub].

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