High-dose inhaled corticosteroids versus add-on long-acting β-agonists in asthma: an observational study

Mike Thomas, Julie von Ziegenweidt, Amanda J. Lee, David Price

Research output: Contribution to journalArticle

47 Citations (Scopus)

Abstract

Background: Guidelines recommend that for patients uncontrolled on inhaled corticosteroids (ICSs), step-up options include an increase in ICS dosage or addition of a long-acting beta-agonist (LABA). Controversy persists about the best option in routine practice.

Objective: To compare asthma outcomes in patients whose first step-up from ICS monotherapy was by addition of LABA (LABA cohort) or increase in ICS dosage or formulation (ICS cohort).

Methods: Observational study using the General Practice Research Database, comparing outcomes in the following 12 months with regression modeling allowing for baseline cohort differences: age, sex, socioeconomic status, body mass index, comorbidity (rhinitis, heart disease), smoking status, short-acting beta-agonist (SABA) use, oral corticosteroid use, and use of asthma complicating medication.

Results: We found 46,930 patients in the ICS and 17,418 in the LABA cohort. In adjusted analysis, the odds ratio (95% CI) of successful treatment (no hospitalization, no oral corticosteroid use, average daily SABA use <1 dose/d) was lower in the ICS cohort (0.75; 0.72-0.79). The adjusted odds ratio of needing rescue SABA prescriptions was higher in the ICS cohort (1.67; 1.59-1.76). However, the adjusted odds of using any oral corticosteroids were lower (0.75; 0.71-0.78), particularly of using 3 or more courses (0.50, 0.46-0.55), and the adjusted odds of respiratory hospitalization were lower (0.69; 0.59-0.81).

Conclusion: Although symptomatic control and rescue bronchodilator use may be improved by the addition of a LABA to ICS, there may be a lower risk of severe exacerbations and hospitalizations from ICS dose increase. (J Allergy Clin Immunol 2009;123:116-21.)

Original languageEnglish
Pages (from-to)116-121.e10
Number of pages6
JournalJournal of Allergy and Clinical Immunology
Volume123
Issue number1
Early online date5 Nov 2008
DOIs
Publication statusPublished - Jan 2009

Keywords

  • asthma
  • long-acting beta-agonist
  • inhaled corticosteroid
  • safety
  • inflammation
  • observational study
  • salmeterol
  • exacerbations
  • adults
  • metaanalysis
  • perspective
  • population
  • severity
  • disease
  • risks

Cite this

High-dose inhaled corticosteroids versus add-on long-acting β-agonists in asthma : an observational study. / Thomas, Mike; von Ziegenweidt, Julie; Lee, Amanda J.; Price, David.

In: Journal of Allergy and Clinical Immunology, Vol. 123, No. 1, 01.2009, p. 116-121.e10.

Research output: Contribution to journalArticle

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abstract = "Background: Guidelines recommend that for patients uncontrolled on inhaled corticosteroids (ICSs), step-up options include an increase in ICS dosage or addition of a long-acting beta-agonist (LABA). Controversy persists about the best option in routine practice.Objective: To compare asthma outcomes in patients whose first step-up from ICS monotherapy was by addition of LABA (LABA cohort) or increase in ICS dosage or formulation (ICS cohort).Methods: Observational study using the General Practice Research Database, comparing outcomes in the following 12 months with regression modeling allowing for baseline cohort differences: age, sex, socioeconomic status, body mass index, comorbidity (rhinitis, heart disease), smoking status, short-acting beta-agonist (SABA) use, oral corticosteroid use, and use of asthma complicating medication.Results: We found 46,930 patients in the ICS and 17,418 in the LABA cohort. In adjusted analysis, the odds ratio (95{\%} CI) of successful treatment (no hospitalization, no oral corticosteroid use, average daily SABA use <1 dose/d) was lower in the ICS cohort (0.75; 0.72-0.79). The adjusted odds ratio of needing rescue SABA prescriptions was higher in the ICS cohort (1.67; 1.59-1.76). However, the adjusted odds of using any oral corticosteroids were lower (0.75; 0.71-0.78), particularly of using 3 or more courses (0.50, 0.46-0.55), and the adjusted odds of respiratory hospitalization were lower (0.69; 0.59-0.81).Conclusion: Although symptomatic control and rescue bronchodilator use may be improved by the addition of a LABA to ICS, there may be a lower risk of severe exacerbations and hospitalizations from ICS dose increase. (J Allergy Clin Immunol 2009;123:116-21.)",
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AB - Background: Guidelines recommend that for patients uncontrolled on inhaled corticosteroids (ICSs), step-up options include an increase in ICS dosage or addition of a long-acting beta-agonist (LABA). Controversy persists about the best option in routine practice.Objective: To compare asthma outcomes in patients whose first step-up from ICS monotherapy was by addition of LABA (LABA cohort) or increase in ICS dosage or formulation (ICS cohort).Methods: Observational study using the General Practice Research Database, comparing outcomes in the following 12 months with regression modeling allowing for baseline cohort differences: age, sex, socioeconomic status, body mass index, comorbidity (rhinitis, heart disease), smoking status, short-acting beta-agonist (SABA) use, oral corticosteroid use, and use of asthma complicating medication.Results: We found 46,930 patients in the ICS and 17,418 in the LABA cohort. In adjusted analysis, the odds ratio (95% CI) of successful treatment (no hospitalization, no oral corticosteroid use, average daily SABA use <1 dose/d) was lower in the ICS cohort (0.75; 0.72-0.79). The adjusted odds ratio of needing rescue SABA prescriptions was higher in the ICS cohort (1.67; 1.59-1.76). However, the adjusted odds of using any oral corticosteroids were lower (0.75; 0.71-0.78), particularly of using 3 or more courses (0.50, 0.46-0.55), and the adjusted odds of respiratory hospitalization were lower (0.69; 0.59-0.81).Conclusion: Although symptomatic control and rescue bronchodilator use may be improved by the addition of a LABA to ICS, there may be a lower risk of severe exacerbations and hospitalizations from ICS dose increase. (J Allergy Clin Immunol 2009;123:116-21.)

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KW - metaanalysis

KW - perspective

KW - population

KW - severity

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