Efficacy of inhaled corticosteroids in asthma,☆☆,

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Abstract

Inhaled corticosteroids have now become established as first-line therapy for patients with persistent asthma. Corticosteroids are the only currently available asthma therapy that suppress inflammation in asthmatic airways, and they inhibit almost every aspect of the inflammatory process in asthma. Inhaled corticosteroids are effective in most patients with asthma, irrespective of age or asthma severity. They not only control asthma symptoms and improve lung function but also prevent exacerbations and may reduce asthma mortality and the irreversible changes in airway function that occur in some patients. The dose-response curve to inhaled corticosteroids is relatively flat, and there is increasing evidence that addition of another class of therapy (long-acting inhaled β2 -agonists, low-dose theophylline, or antileukotrienes) may be preferable to increasing the dose of inhaled corticosteroids in patients with moderate-to-severe asthma. Inhaled corticosteroids are convenient to use and are the most cost-effective treatment currently available for long-term asthma control. A small proportion of patients are resistant to the antiinflammatory effects of corticosteroids. Future developments may include inhaled corticosteroids with even fewer systemic effects or more specific antiinflammatory drugs. (J Allergy Clin Immunol 1998;102:531-8.)

Section snippets

ANTIINFLAMMATORY MECHANISMS

Corticosteroids are very effective at suppressing the eosinophilic inflammation in the airways of patients with asthma. This antiinflammatory effect is through increased transcription and expression of antiinflammatory proteins, such as IL-1 receptor antagonist, IL-10, and neutral endopeptidase. More importantly, this effect is through repression of inflammatory genes, such as cytokines involved in the inflammatory response in asthma (eg, IL-4, IL-5, and chemokines involved in eosinophil

CLINICAL EFFICACY

Inhaled corticosteroids are very effective in controlling asthma symptoms in asthmatic patients of all ages with asthma of all severities (Table I).1, 5, 6

. Effects of inhaled corticosteroids in asthma

• Control symptoms
• Improve quality of life
• Improve lung function
• Prevent exacerbations
• Reduce mortality (probably)
• Prevent irreversible airway changes
• Alter natural history of asthma (?)
Inhaled corticosteroids improve the quality of life of patients with asthma and may allow patients to lead

CLINICAL USE OF INHALED CORTICOSTEROIDS

Inhaled corticosteroids are now recommended as first-line therapy for all patients with persistent symptoms.1 Inhaled corticosteroids should be started in any patient who needs to use a β2 -agonist inhaler for symptom control more than once daily (or possibly 3 times weekly). It is conventional to start with a low dose of inhaled corticosteroid and to increase the dose until asthma control is achieved. However, this may take time, and a preferable approach is to start with a dose of

CORTICOSTEROID-RESISTANT ASTHMA

Although glucocorticoids are highly effective in the control of asthma and other chronic inflammatory or immune diseases, a small proportion of patients with asthma fail to respond even to high doses of oral glucocorticoids.38, 39 Resistance to the therapeutic effects of glucocorticoids is also recognized in other inflammatory and immune diseases, including rheumatoid arthritis and inflammatory bowel disease. Corticosteroid-resistant patients, although uncommon, present considerable management

FUTURE DIRECTIONS

Inhaled corticosteroids are now used as first-line therapy for the treatment of persistent asthma in adults and children in many countries because they are the most effective treatments for asthma currently available. The recent trend to start with a relatively high dose of inhaled corticosteroids to achieve more rapid control of asthma before the dose is reduced to the minimum needed to maintain control may lead to lower overall maintenance doses.6 Although many patients, particularly those

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    From the National Heart and Lung Institute, Imperial College, London.

    ☆☆

    Reprint requests: Peter J. Barnes, Department of Thoracic Medicine, National Heart and Lung Institute, Dovehouse St, London SW3 6LY, UK.

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