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Optimizing Medications for Poorly Controlled Asthma

The goals of asthma therapy are to maintain long-term control of asthma symptoms, prevent exacerbations, attain the best possible lung function for daily activities, and minimize side effects. Inflammation is a critical feature in the pathogenesis of asthma and, consequently, inhaled corticosteroids (ICS) are the mainstay of treatment. There have been several randomized studies demonstrating that ICS reduce asthma symptoms, improve lung function, reduce the frequency of acute exacerbations, and improve airway hyperresponsiveness (1, 2).

In the trial by the American Lung Association Asthma Clinical Research Centers (3), investigating the addition of montelukast or low-dose theophylline in patients with poorly controlled asthma, it is surprising that 20 to 25% of the subjects were not receiving ICS, indicating suboptimal asthma therapy. Furthermore, 18 to 23% were receiving inhaled long-acting ₂-agonists alone as monotherapy without ICS. This would again appear to represent suboptimal therapy based on the results of the study by Nelson and coworkers (4), which reported a small but significant increase in respiratory- and asthma-related deaths in subjects receiving salmeterol predominantly as monotherapy. Deykin and coworkers (5) demonstrated that the combination of ICS and salmeterol outperformed the alternative novel approach of combining montelukast with inhaled long-acting ₂-agonists for management of moderate asthma. These findings continue to support the view that ICS should be initiated as first-line treatment in all patients with poorly controlled asthma. Low-dose theophylline or montelukast appear to have limited utility in this setting even as second-line agents, whereas monotherapy with inhaled long-acting ₂-agonists should be discouraged.

Andrew Tai and Sarath Ranganathan

Royal Children's Hospital, Melbourne, Australia

FOOTNOTES

Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

REFERENCES

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