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Should steroids be the first line treatment for asthma?

Step one of the current British asthma guidelines recommends that inhaled short acting β₂ agonists should be used as required. Some clinicians, including George Strube, a general practitioner from Crawley, believe that this step is unnecessary and that steroids should be introduced earlier. Michael Rudolph, a consultant physician from Ealing Hospital, defends the guidelines.

For

George Strube, general practitioner (GStrube@aol.com)

33 Goffs Park Road, Crawley, West Sussex RH11 8AX
Department of Respiratory Medicine, Ealing Hospital NHS Trust, Southall, Middlesex UB1 3HW

Evidence for the inflammatory basis of asthma comes from bronchial biopsies, which show inflammation of the mucosa even in patients with mild intermittent asthma.1 Mucosal oedema and excess mucus production cause reduction in the lumen and obstruction to airflow. Bronchospasm occurs as the natural ‘foreign body’ response to irritation caused by inflammation, the bronchi become hyperactive and the airflow is further reduced. Persistent inflammation may lead to structural changes in the airways, with reduction in lung function and irreversible airways obstruction.2

Steroids and β agonists

Steroids are the most effective anti-inflammatory drugs available. They reduce mucosal oedema and bronchial hyperreactivity thus relieving acute symptoms and preventing structural damage to the lungs. It is therefore best to give them as soon as the diagnosis of asthma has been confirmed.

β Agonists are effective bronchodilators but they have no anti-inflammatory activity and so although they offer temporary clinical improvement the underlying inflammation persists. When their effect wears off there is a return of bronchial hyperreactivity and bronchoconstriction, which may even be increased.3 If this is countered with further doses of bronchodilator a pattern of dependence can be established with regular use aggravating the asthma it is intended to control. This may even occur in patients already taking steroids, and the dose required for control may need to be increased. Regular use of bronchodilators should therefore be avoided and should be kept in reserve for breakthrough wheezing.