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Ann Am Thorac Soc. 2015 Jun;12(6):798-806. doi: 10.1513/AnnalsATS.201412-580OC.

Increased Dose of Inhaled Corticosteroid versus Add-On Long-acting β-Agonist for Step-Up Therapy in Asthma.

Author information

1
1 Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
2
2 Cochin Hospital Group, Assistance Publique-Hôpitaux de Paris, University of Paris Descartes, Paris, France.
3
3 National Jewish Health and University of Colorado Denver, Denver, Colorado.
4
4 Washington Hospital Center and George Washington University School of Medicine, Washington, DC.
5
5 Cipla Europe NV, Antwerp, Belgium.
6
6 Department of Pulmonary Medicine and Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
7
7 Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio.
8
8 Emma Children's Hospital Academisch Medisch Centrum, Amsterdam, The Netherlands; and.
9
9 Blizard Institute, Queen Mary University of London.
10
10 Research in Real-Life, Ltd, Cambridge, and.
11
11 Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom.

Abstract

RATIONALE:

Guidelines advocate adding long-acting β-agonist (LABA) to inhaled corticosteroid as the preferred step-up therapy to increasing inhaled corticosteroid dose for patients with uncontrolled asthma on inhaled corticosteroid monotherapy. However, less than 5% of patients with asthma qualify for the randomized controlled trials on which guidelines are based. Thus, real-world data are needed to complement the results of randomized trials with narrow entry criteria.

OBJECTIVES:

To compare the effectiveness of stepping up asthma therapy with an increased dose of various types of inhaled corticosteroid as compared with add-on LABA.

METHODS:

We performed a historical matched cohort study using large primary care databases to compare asthma step-up therapy with small- and standard size-particle inhaled corticosteroid versus added LABA for patients 12-80 years old. As outcomes, we examined a composite of asthma control and rates of severe exacerbations.

MEASUREMENTS AND MAIN RESULTS:

The odds of asthma control and rates of severe exacerbations over one outcome year were comparable with increased inhaled corticosteroid dose versus added LABA. The adjusted odds ratios (95% confidence interval) for achieving asthma control with increased inhaled corticosteroid dose versus inhaled corticosteroid/LABA were 0.99 (0.88-1.12) for small-particle inhaled corticosteroid (n = 3,036 per cohort) and 0.85 (0.67-1.07) for standard size-particle inhaled corticosteroid (n = 809 per cohort). The adjusted rate ratios (95% confidence interval) for severe exacerbations, compared with inhaled corticosteroid/LABA combination inhaler, were 1.04 (0.91-1.20) and 1.18 (0.92-1.54), respectively. The results were not affected by smoking status.

CONCLUSIONS:

When applied to a broad primary care population, antiinflammatory therapy using increased doses of small- or standard size-particle inhaled corticosteroid is as effective as adding LABA, as measured by outcomes important to both patients and providers. Real-world populations and outcomes need to be taken into consideration when formulating treatment recommendations.

KEYWORDS:

adrenergic β2-agonists; antiasthmatic agents; bronchodilator agents; disease exacerbation; glucocorticoids

Comment in

PMID:
25756308
DOI:
10.1513/AnnalsATS.201412-580OC
[Indexed for MEDLINE]

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