Drug sequencing
Chronic asthma: sequencing drugs
Recommendations:
- the trigger to increasing treatment at all stages is if the short acting inhaled agonist is being used more than two to three times daily or symptom control is
not good (the British Thoracic Society Guidelines define good control as: minimal
(ideally no) chronic symptoms; minimal (infrequent) exacerbations; minimal need for relieving bronchodilators; no limitations on activities) (C)
- compliance should be checked before any treatment increase (C)
- a one to three month period of stability should be shown
before slow stepwise reduction in treatment is undertaken decreasing the dose of
inhaled steroid by approximately 25-50% at each step (C)
Figure 1 - Sequencing treatment algorithm
Recommendations:
- patients should initially be treated with a metered dose inhaler (C)
- if they cannot comply with a metered dose inhaler then a large volume spacer device should be added (C)
- if they cannot comply with a metered dose inhaler plus large volume spacer then they should be treated with the cheapest powder or automatic aerosol inhaler that they can comply with (C)
- if they find a metered dose inhaler plus large volume spacer difficult to carry round during the day because of its bulk then they should be treated with the cheapest powder or automatic aerosol inhaler that they can comply with (C)
Recommendation:
- patients with uncontrolled asthma should be treated with:
-
- prednisolone 30-40 mg daily continued until the episode has resolved, symptoms are controlled, and lung function has returned to previous best levels. While seven days treatment will often be sufficient, it may need to be continued for up to 21 days (C)
-
- depending on the severity of the episode they may need a short acting inhaled beta 2 agonist via either a nebuliser or a large volume spacer device (C)
- Comment:
- The British
Thoracic Society guidelines suggest the need for rescue courses of steroids to
include: symptoms and PEFR get progressively worse day by day; PEFR falls below
60% of patient's best; sleep is disturbed by asthma; morning symptoms persist
until midday; there is diminishing response to inhaled bronchodilators; emergency
use is made of nebulised or injected bronchodilators.
Recommendation:
- patients should not be treated solely with acupuncture (A)
Statement: acupuncture has not been
demonstrated to be of any therapeutic benefit in patients with asthma (I). Tashkin et al. (1985) studied 25 patients who received
classical Chinese acupuncture or placebo acupuncture in random order within a
crossover design. Each treatment period was for four weeks. There was no
effect, in either arm of the study, on lung function measurements, symptoms or
medication use. There is no power calculation. (NB. This was the highest
scoring study in Kleijnen's systematic review cited below).
In a
qualitative systematic review of trials of acupuncture Kleijnen et al.
(1991) reviewed 13 trials using explicit methodological criteria which resulted
in an overall score for each trial. The quality of the studies was not high and
the results from the better studies were contradictory.
Comment: The use of acupuncture as treatment for asthma should await
the demonstration of its effectiveness.
- References
- Kleijnen, J., ter
Riet, G. and Knipschild, P. (1991) Acupuncture and asthma: a review of controlled
trials. Thorax 46:799-802.
Tashkin, D.P.,
Kroening, R.J., Bresler, D.E., Simmons, M., Coulson, A.H. and Kerschnar, H.
(1985) A controlled trial of real and simulated acupuncture in the management of
chronic asthma. Journal of Allergy and Clinical Immunology
76:855-864.
Recommendation:
- patients should not be treated solely with yoga (A)
Statement: yoga has not been demonstrated
to be of any therapeutic benefit in patients with asthma (I). Singh et al. (1990) studied 22 patients with mild asthma in
a randomised, double blind, placebo controlled crossover trial. For two week
periods the patients breathed either through a device called the pink city lung
that imposes slowing of breathing equivalent to the pranayama breathing method,
or through a matched placebo device. There were no significant changes in FEV1,
PEFR, symptoms or inhaler use. There was a significant improvement in airway
reactivity during the yoga period compared to placebo.
- Comment:
- We only identified one study of yoga; while spirometry did not
change, bronchial reactivity decreased suggesting some effect from the
intervention. This merits further study.
- References
- Singh, V., Wisniewski,
A., Britton, J. and Tattersfield, A. (1990) Effect of yoga breathing exercises
(pranayama) on airway reactivity in subjects with asthma [see comments].
Lancet 335:1381-1383.
Research questions
What is the place of complementary medicine in the treatment of
asthma?