© 2005 American Thoracic Society doi: 10.1164/rccm.2505005
Concluding Statement
a St. Joseph's Hospital and McMaster University, Hamilton, Ontario, Canada The question prompting this PRO/CON debate is whether daily use of a low dose of an inhaled corticosteroid for mild persistent asthma is worth it to patients (as indicated by their willingness to pay for and use the medication) and to society in general (by reducing the costs associated with exacerbation risks or progressive loss of pulmonary function). The only way to answer the "worth it" question is to undertake a large, prospective effectiveness study of the clinical and economic benefits of regular, daily low-dose ICS versus only "as needed" corticosteroid treatment in this population under "real world" conditions. This study would best be performed in collaboration with primary care providers, who care for 70% of patients with asthma in North America. The study should be large enough to ensure the certainty and generalizability of its findings, and long enough to detect a modest difference in the annual rate of "irreversible" loss in FEV1. If large enough, and with enough exacerbations, such a study would also offer a chance to examine prospectively possible phenotypic or genotypic markers of risk for exacerbations or for progressive loss of pulmonary function. An incomplete list of some of the features that might estimate an individual patient's risk could include responses to a questionnaire about the features and triggers of previous attacks; domestic exposure to secondhand tobacco smoke, pets, or molds; the history of changes in asthma symptoms during "colds"; IgE level; cutaneous reactivity to common antigens; bronchodilator responsiveness; bronchial reactivity; sputum or blood eosinophilia; and the concentration of gases or other compounds in exhaled air, whether in gaseous (e.g., exhaled nitric oxide) or condensed form (e.g., leukotriene-E4). The benefit of such a study is that it would help answer the outstanding clinical and economic questions about regular treatment in this large population of individuals with asthma, and might help identify the individual patients who most need treatment. A disadvantage is that these studies are often thought of as marketing tools of the pharmaceutical industry and can be difficult to enter into the archival literature. Another benefit, though, is that it would give us something to agree on, as we already agree in recommending it.
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