ArticlesDoubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial
Introduction
Asthma guidelines recommend regular inhaled corticosteroid treatment for patients with persistent asthma and daily symptoms needing β-agonist treatment.1, 2 In patients with symptomatic but fairly stable asthma, doubling3, 4 or quadrupling5 the dose of inhaled corticosteroid leads to modest changes in spirometry and peak flow. Doubling the dose of inhaled corticosteroid when asthma control deteriorates is widely advocated but is of unproven value. We aimed to investigate whether doubling the dose of inhaled corticosteroid when asthma control starts to deteriorate reduces the number of patients needing prednisolone, and to establish the effect on the severity and duration of the subsequent exacerbation.
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Patients
We recruited individuals aged 16 years and older with a clinical diagnosis of asthma and taking an inhaled corticosteroid (100 to 2000 μg per day) on a regular basis from local general practices and our asthma research register. To be included, individuals had to have taken a course of oral corticosteroids or doubled their dose of inhaled corticosteroid temporarily in the previous 12 months to treat or prevent an asthma exacerbation. Exclusion criteria were history of smoking of more than 10
Results
Table 1 shows details of 390 participants who fulfilled the entry criteria and were randomly allocated to provide two well matched treatment groups. 17 and 20 individuals withdrew from the active and placebo groups, respectively (ten and 11 were lost to follow-up, three and seven for personal reasons, and four and two on the advice of their general practitioner [figure 1]). About half (207) started the study inhaler; almost 60% in the active group and about 50% in the placebo group. Of the 207
Discussion
We have recorded little evidence to lend support to the widely recommended intervention of doubling the dose of inhaled corticosteroid when asthma control starts to deteriorate. When compared with placebo, doubling the dose of inhaled corticosteroid had no effect on the number of patients needing prednisolone, lowest peak flow recorded, rise in symptom scores, highest symptom score recorded, or time to recovery for peak flow and symptom scores. The fall in peak flow while taking the study
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