Should mild persistent asthma be treated with rescue albuterol alone?

To assess whether a combination of inhaled beclomethasone plus albuterol could be used as a rescue medication regimen to reduce the frequency of exacerbations, whether the patient also used daily beclomethasone, investigators conducted a 44-week trial with 4 treatment groups: twice-daily beclomethasone with beclomethasone plus albuterol as rescue (combined group); twice-daily beclomethasone with placebo plus albuterol as rescue (daily beclomethasone group); twice-daily placebo with beclomethasone plus albuterol as rescue (rescue beclomethasone group); and twice-daily placebo with placebo plus albuterol as rescue (placebo group).

Twice-daily beclomethasone treatment was 1 puff of beclomethasone given in the morning and evening; rescue beclomethasone treatment was 2 puffs of beclomethasone for each 2 puffs of albuterol needed for symptom relief. Exacerbations were defined by a need for a course of oral corticosteroids in addition to the assigned rescue plan. Trial participants were 288 children and adolescents from 5 to 18 years old drawn from 5 clinical centers throughout the country.

By the end of the trial, the probability of a first exacerbation was lowest in the groups that used daily inhaled corticosteroids: 31% in the combined group and 28% in the daily-beclomethasone group. In the rescue-beclomethasone group, that figure was 35%, and it was highest (49%) in the placebo group. During the course of the trial, 29 treatment failures occurred, 60% of which were in the placebo group. Treatment failure was defined as needing a second dose of prednisone within any 6-month period.

Commentary

How many times have you reminded a parent or patient that inhaled steroids are a preventive, not a rescue, medication for asthma? Well, at least for some patients, we may need to change that advice. This study shows that inhaled steroids have a role in preventing asthma exacerbations, even for mild persistent asthma. Adherence to a daily medication for mild asthma is often problematic, however. If patients can't comply with a daily regimen, then addition of inhaled steroids with acute onset of symptoms sometimes may avert a full-blown asthma exacerbation. And this approach may prevent a bit of growth loss as well. -Michael Burke, MD