Should be more frequently used
3-7 INHALED STEROIDS AND THE RISK OF HOSPITALIZATION FOR ASTHMA
In 1991, a National Institute of Health Guideline promoted a multifaceted approach to asthma care. A key element was the use of anti-inflammatory pharmaco-therapy (particularly inhaled corticosteroids) early in the treatment of moderate to severe disease. Although widely disseminated, there has been little evidence to support the effectiveness of the recommendations in improving outcomes.
This study was designed to determine if anti-inflammatory treatment reduces the risk of hospitalization for asthma.
Conclusion: Inhaled steroids conferred significant protection against exacerbations of asthma leading to hospitalization.

STUDY

1. Followed over 16 000 enrolled in a HMO. All were diagnosed as having asthma.
2. Determined rate of hospitalization for asthma and types of drugs dispensed to treat asthma.

RESULTS

1. Over 3 years, 4.4% of patients were hospitalized for asthma.
2. The overall relative risk (RR) of hospitalization among those who received inhaled steroids was 0.5 (after adjustment) compared with patients for whom no steroids were dispensed.
3. In contrast, increased beta-agonist use was associated with increasing risk of hospitalization—a 4-fold increase among those dispensed more than 8 prescriptions per person-year relative to those dispensed no beta-agonists. However, those who received beta-agonists up to 3 per person-year were less likely to be hospitalized than those dispensed no beta-agonists.
4. The rate of hospitalization was lower among inhaled steroid recipients in each category of beta-agonist exposure (compared with those receiving no beta-agonist). The protective effect of inhaled steroids was evident in patients with all degrees of severity of asthma, but was more pronounced in patients for whom beta-agonists were dispensed more frequently (those with more severe asthma). For those who received one beta-agonist per year, the relative risk of hospitalization in those who also received steroids was reduced by 40%; for those who received 8 or more beta-agonists as well as inhaled steroids risk of hospitalization was reduced by 70%.

DISCUSSION

1. Inhaled steroids were associated with a substantial decrease in the risk of hospitalization for asthma, although this effect was only apparent after adjustment for beta-agonist dispensing.
2. Steroids are more likely to be prescribed for persons with more severe asthma. In this study adjustment for the amount of beta-agonist dispensed may have served as a surrogate for asthma severity.
3. The current study, which found a doubling of hospitalizations among those who received neither beta-agonists nor inhaled steroids, is consistent with an underappreciation of disease severity.
4. In another study, the only modifiable risk factor for emergency department visits was under medication; nearly half of those who used the ED were not taking inhaled steroids. "Our results were comparable: 64% of those hospitalized were not dispensed inhaled steroids prior to their admission."
5. While the risks associated with high-dose, long-term use of inhaled steroids have not been completely defined, there have been relatively few adverse effects associated with conventional low doses. This has prompted some to recommend routine use of inhaled steroids even in cases of mild asthma.

CONCLUSION
Inhaled steroids conferred significant protection against exacerbations of asthma leading to hospitalization. The effect was most pronounced when there was moderate or greater use of beta-agonists. These results support the use of inhaled steroids by individuals who require more than occasional beta-agonist use to control asthma.
JAMA March 19, 1997; 277:887-91 Original investigation from Brigham and Womens Hospital, Boston, Mass.

[index]