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Povišena ili stabilna doza inhalacijskih kortikosteroida za pogoršanja kronične astme u odraslih i djece

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Abstract

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Background

Written action plans providing guidance in the early treatment of asthma exacerbations have traditionally advocated doubling of inhaled corticosteroids (ICS) as one of the first steps in treatment.

Objectives

To compare the clinical effectiveness of increasing the dose of ICS versus keeping the usual maintenance dose as part of a patient‐initiated action plan at the onset of asthma exacerbations.

Search methods

We searched the Cochrane Airways Group Specialised Register (last search October 2009) which is derived from searches of CENTRAL, MEDLINE, EMBASE and CINAHL, as well as handsearched respiratory journals and meeting abstracts.

Selection criteria

Randomised controlled trials (RCTs) that compared the strategy of increasing the daily dose of ICS to continuing the same ICS dose in the home management of asthma exacerbations in children or adults with persistent asthma on daily maintenance ICS.

Data collection and analysis

Two review authors independently selected trials, assessed quality and extracted data. We contacted authors of RCTs for additional information.

Main results

Five RCTs (four parallel‐group and one cross‐over) involving a total of 1250 patients (28 children and 1222 adults) with mild to moderate asthma were included. The mean daily baseline ICS dose was 555 mcg (range 200 mcg to 795 mcg) and the mean daily ICS dose achieved following increase was 1520 mcg (range 1000 mcg to 2075 mcg), in CFC beclomethasone dipropionate equivalents. Three parallel‐group studies in adults (two doubling and one quadrupling; mean achieved daily dose of 1695 mcg with a range of 1420 to 2075 mcg), involving 1080 patients contributed data to the primary outcome. There was no significant reduction in the need for rescue oral corticosteroids when patients were randomised to the increased ICS compared to stable maintenance dose groups (OR 0.85, 95% CI 0.58 to 1.26). There was no significant difference in the overall risk of non‐serious adverse events associated with the increased ICS dose strategy, but the wide confidence interval prevents a firm conclusion. No serious adverse events were reported.

Authors' conclusions

There is very little evidence from trials in children. In adults with asthma on daily maintenance ICS, a self‐initiated ICS increase to 1000 to 2000 mcg/day at the onset of an exacerbation is not associated with a statistically significant reduction in the risk of exacerbations requiring rescue oral corticosteroids. More research is needed to assess the effectiveness of increased ICS doses at the onset of asthma exacerbations (particularly in children).

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Laički sažetak

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Povišena ili stabilna doza inhalacijskih kortikosteroida za pogoršanja kronične astme u odraslih i djece

U ranijim smjernicama za liječenje astme zagovaralo se udvostručenje doze inhalacijskih kortikosteroida za rano liječenje pogoršanja astme. U ovom Cochrane sustavnom pregledu pronađeno je 5 istraživanja u kojima je sudjelovalo ukupno 1250 ispitanika, u kojima je usporeden učinak povećane doze inhalacijskog kortikosteroida ili uzimanje uobičajene doze održavanja tijekom pogoršanja (egzacerbacije) astme. Pacijenti koji su bili u skupni koja je uzimala povećanu dozu inhalacijskog kortikosteroida nisu imali značajno manju potrebu za dodatnim kortikosteroidima koji se uzimaju na usta u odnosu na pacijente koji su nastavili uzimati njihovu stabilnu, uobičajenu dozu inhalacijskih kortikosteroida. Ni u drugim rezultatima nije bilo pokazatelja da postoje razlike između ta dva pristupa liječenju. Povećana doza nije bila povezana s povećanim rizikom od nuspojava. Potrebno je više istraživanja kako bi se bolje procijenila djelotvornost povećane doze inhalacijskih istraživanja tijekom egzacerbacija astme, osobito u djece.