Standard approach to mild asthma often falls short

Many patients with mild asthma may not benefit from inhaled steroid medications, the current standard treatment, according to the results of a new clinical trial.

People with persistent asthma commonly receive prescriptions for inhaled glucocorticoids, a type of steroid which reduces inflammation in the airways. However, the medications are not always effective in all patients, suggesting that different forms of asthma may require different treatments.

“Healthcare providers need a way to decide which patients might benefit from a steroid medication versus another, non-steroid type of controller medication,” says coauthor Jacqueline Pongracic, chief of allergy and immunology in the pediatrics department at the Feinberg School of Medicine at Northwestern University and division head of allergy and immunology at Ann & Robert H. Lurie Children’s Hospital of Chicago.

“…asthma guidelines should be re-assessed for patients with mild asthma…”

In the current study, investigators focused on levels of an inflammatory cell called eosinophils in the sputum (mucus from the lungs) of patients, as previous research had suggested that asthma patients with less than 2 percent sputum eosinophils may not respond well to glucocorticoids.

The multicenter study, which included 295 people over the age of 12 with mild persistent asthma, first classified participants as having either low or high sputum eosinophil levels. The investigators discovered that 73 percent of participants had low eosinophil levels—a much higher rate than they expected.

The trial then compared how patients, based on their sputum eosinophil levels, responded to three treatments: either mometasone (a common inhaled glucocorticoid), tiotropium (a non-steroid asthma medication), or placebo.

The investigators found that patients classified as low eosinophil responded no better to either of the treatments than they did to placebo. In contrast, the smaller group of patients considered to have high eosinophil levels were significantly more likely to respond to the inhaled glucocorticoids than to placebo.

According to the authors, more research is needed to determine alternative treatments for patients with low eosinophil levels, for whom inhaled glucocorticoids may not be appropriate.

“The study findings suggest that asthma guidelines should be re-assessed for patients with mild asthma who do not have high levels of eosinophils in their sputum, so that options that do not carry steroid side effects might be considered as first-line treatment,” Pongracic says.

The research appears in the New England Journal of Medicine.

The National Heart, Lung, and Blood Institute supported the research. Boehringer Ingelheim provided the tiotropium and tiotropium placebo. Merck provided mometasone and mometasone placebo. Teva provided albuterol.

Source: Anna Williams for Northwestern University

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