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Rapid Responses: Rapid Responses published:
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Why use a sledgehammer to crack a nut!
- Cathy Jackson (1 January 2000)
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agree with the British gudelines for step one bronchial asthma treatment
- Ivan Rodriguez (2 January 2000)
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Don't forget the difficulties in children
- John Furness (2 January 2000)
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A Probable Solution
- Ching-Chee Chan (14 January 2000)
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Cathy Jackson, GP Westgate Health Centre,Dundee
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I do not agree with Dr Strube who argues for the use of inhaled steroid for all patients with asthma including those with episodic mild disease[ie step1] .Even if patients with non persistent mild asthma were given inhaled steroid,the likelihood is that in the real world they would not comply and only use them as required for episodic symptoms.As Dr Rudolf points out inhaled steroids do not work quickly and hence it is more rationale to use a fast acting reliever in situations of episodic wheeze at step 1 .Another potential problem with Dr Strube's philosophy is that patients who only use their brown inhaler for episodic symptoms will lose confidence when they find it does not work quickly,and subsequently may be less inclined to take regular inhaled steroid if they really need it for persistent asthma.It does not make sense to use your best drug first if you don't actually need it. Dr Strube also suggests that inhaled steroids are the only truly anti -inflammatory drug for 1st line therapy.This is clearly not the case as there are biopsy studies with cromolyn and leukotriene antagonists showing reductions in a variety of inflammatory cells such as mast cells ,eosinophils and lymphocytes.With the recent class labelling of all inhaled steroids by FDA and MCA with a precautionary note on possible growth suppression in children, it would be unwise to expose all children with mild asthma to inhaled steroids. I would particularly take issue with Dr Strube's suggestion for starting all asthmatics on high dose inhaled steroid as my own experience from primary and secondary care asthma clinics is that patients are often not tapered to a minimal effective maintainence dose and are exposed to higher than necessary doses.Furthermore there is no good evidence for a dose response with inhaled steroid above 400ug/day of beclomethasone or equivalent in patients in mild to moderate asthma . I would therefore agree with Dr Rudolf that there is no rationale to deviate from the recomended guidelines in terms of reserving inhaled steroid for patients with mild to moderate persistent asthma at step 2 or above. |
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Ivan Rodriguez, family physician private practice. Savanna la Mar Jamaica
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Dr. Rudolph's comments about the British guidelines for step one bronchial asthma treatment in my opinion are correct. I belive that a child who has mild intermitent bronchial asthma, whose P.E.F. is 80 % OR more of his/her ideal value and who does not have nocturnal symptoms in between episodes should not be started on inhaled steroids (for many reasons that we all know, specially side effects). There is a point on the treatment of bronchial asthma which neither Dr. Strub or Dr. Rudolph mentioned in their comments; it is the use of mast-cell stabilizer in the treatment of bronchial asthma in children. I belive that for a child who has mild bronchial asthma (Intermitent, non severe episodes which can be easily managed at O.P.D. or private office and whose P.E.F. in between episodes is 80% or more of her/his ideal value) mast-cell stabilizer and B2 agonist should be the start point. |
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John Furness, SpR paediatrivcs Sunderland
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I was very interested in the article by Strube and Rudolf (1). I would like to highlight some points in respect of children . Rudolf comments that steroids are being overused in children as they are not being stepped down according to BTS guidelines (2). This is not an arguement for avoiding steroids but for following the guidelines ( Rudolf makes exactly the same arguement in support or step 1 ). Currently it is impossible to differentiate asthma from other causes of wheeze in infants and so a therapeutic trial of steroids is a pragmatic way forward in this group. My understanding of the consensus is to try steroids in wheezy infants but remeber to stop them if they have no benefit. 1. Strube and Rudolf For and Against: Should steroids be the first line of treatment for asthma? BMJ 2000; 320: 47-49 2. The British guidelines on asthma management 1995: review and position statement. Thorax 1997; 52( S1): 1-21S Cmpeteing interests: none |
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Ching-Chee Chan, Publisher Egret Publishing Inc.
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A curve of asthma prevalence (Haahtela T, Lindholm H, Bjorksten F, koskenvuo K, Laitinen LA. Prevalence of asthma in Finnish young men. BMJ 1990; 301 (6746): 266-268) rises from 1961 to 1989 by about 2000%. Many diseases related to the immune system show similar variation patterns from 1960 to 1993. These diseases cover the fields of neurological, respiratory, musculo-skeletal, connective tissue, digestive, endocrine and vascular systems. Hansen's bacterium is known to be capable of affecting most of these systems. This bacterium can be detected by means of PCR methods and it can be destroyed by antibiotics. For further details, see "An Alternative Approach to AIDS and Related Problems" and "An Alternative Approach to AIDS and Related Problems: Book 2." Shortened versions of these two booklets are available free online, URL http://webhome.idirect.com/~egretinc/shortver.html Competing interests: author and publisher of the two booklets listed above. |
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