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Meta-Analysis
. 2016 Jun 7;2016(6):CD007524.
doi: 10.1002/14651858.CD007524.pub4.

Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children

Kayleigh M Kew  1 , Michael Quinn, Bradley S Quon, Francine M Ducharme
Affiliations
Meta-Analysis

Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children

Kayleigh M Kew et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: People with asthma may experience exacerbations or "attacks" during which their symptoms worsen and additional treatment is required. Written action plans may advocate doubling the dose of inhaled steroids in the early stages of an asthma exacerbation to reduce the severity of the attack and to prevent the need for oral steroids or hospital admission.

Objectives: To compare the clinical effectiveness and safety of increased versus stable doses of inhaled corticosteroids (ICS) as part of a patient-initiated action plan for home management of exacerbations in children and adults with persistent asthma.

Search methods: We searched the Cochrane Airways Group Specialised Register, which is derived from searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to March 2016. We handsearched respiratory journals and meeting abstracts.

Selection criteria: We included randomised controlled trials (RCTs) that compared increased versus stable doses of ICS for home management of asthma exacerbations. We included studies of children or adults with persistent asthma who were receiving 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: This review update added three new studies including 419 participants to the review. In total, we identified eight RCTs, most of which were at low risk of bias, involving 1669 participants with mild to moderate asthma. We included three paediatric (n = 422) and five adult (n = 1247) studies; six were parallel-group trials and two had a cross-over design. All but one study followed participants for six months to one year. Allowed maintenance doses of ICS varied in adult and paediatric studies, as did use of concomitant medications and doses of ICS initiated during exacerbations. Investigators gave participants a study inhaler containing additional ICS or placebo to be started as part of an action plan for treatment of exacerbations.The odds of treatment failure, defined as the need for oral corticosteroids, were not significantly reduced among those randomised to increased ICS compared with those taking their usual stable maintenance dose (odds ratio (OR) 0.89, 95% confidence interval (CI) 0.68 to 1.18; participants = 1520; studies = 7). When we analysed only people who actually took their study inhaler for an exacerbation, we found much variation between study results but the evidence did not show a significant benefit of increasing ICS dose (OR 0.84, 95% CI 0.54 to 1.30; participants = 766; studies = 7). The odds of having an unscheduled physician visit (OR 0.96, 95% CI 0.66 to 1.41; participants = 931; studies = 3) or acute visit (Peto OR 0.98, 95% CI 0.24 to 3.98; participants = 450; studies = 3) were not significantly reduced by an increased versus stable dose of ICS, and evidence was insufficient to permit assessment of impact on the duration of exacerbation; our ability to draw conclusions from these outcomes was limited by the number of studies reporting these events and by the number of events included in the analyses. The odds of serious events (OR 1.69, 95% CI 0.77 to 3.71; participants = 394; studies = 2) and non-serious events, such as oral irritation, headaches and changes in appetite (OR 2.15, 95% CI 0.68 to 6.73; participants = 142; studies = 2), were neither increased nor decreased significantly by increased versus stable doses of ICS during an exacerbation. Too few studies are available to allow firm conclusions on the basis of subgroup analyses conducted to investigate the impact of age, time to treatment initiation, doses used, smoking history and the fold increase of ICS on the magnitude of effect; yet, effect size appears similar in children and adults.

Authors' conclusions: Current evidence does not support increasing the dose of ICS as part of a self initiated action plan to treat exacerbations in adults and children with mild to moderate asthma. Increased ICS dose is not associated with a statistically significant reduction in the odds of requiring rescue oral corticosteroids for the exacerbation, or of having adverse events, compared with a stable ICS dose. Wide confidence intervals for several outcomes mean we cannot rule out possible benefits of this approach.

PubMed Disclaimer

Conflict of interest statement

Kayleigh Kew: none.

Michael Quinn: none.

Bradley Quon: none.

Francine Ducharme: grant support for investigator‐initiated studies from Merck and Co., unrestricted donations from Merck, GlaxoSmithKline, and Takeda, to support an electronic database of children consulting for asthma; member of the advisory boards of Boehringer Ingelheim.

Figures

1
1
Study flow diagram.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study
1.1
1.1. Analysis
Comparison 1 Increased versus stable doses of ICS, Outcome 1 Treatment failure ‐ need for systemic corticosteroids (primary outcome, all randomised participants).
1.2
1.2. Analysis
Comparison 1 Increased versus stable doses of ICS, Outcome 2 Treatment failure ‐ need for systemic corticosteroids (of those starting inhaler).
1.3
1.3. Analysis
Comparison 1 Increased versus stable doses of ICS, Outcome 3 Unscheduled physician visits.
1.4
1.4. Analysis
Comparison 1 Increased versus stable doses of ICS, Outcome 4 Unscheduled acute care, ED visit or hospital admission.
1.5
1.5. Analysis
Comparison 1 Increased versus stable doses of ICS, Outcome 5 Duration of exacerbation.
1.6
1.6. Analysis
Comparison 1 Increased versus stable doses of ICS, Outcome 6 Serious and non‐serious adverse events.
2.1
2.1. Analysis
Comparison 2 Primary outcome subgroup and sensitivity analyses, Outcome 1 Subgrouped by age.
2.2
2.2. Analysis
Comparison 2 Primary outcome subgroup and sensitivity analyses, Outcome 2 Subgrouped by time to treatment initiation.
2.3
2.3. Analysis
Comparison 2 Primary outcome subgroup and sensitivity analyses, Outcome 3 Subgrouped by maintenance ICS dose.
2.4
2.4. Analysis
Comparison 2 Primary outcome subgroup and sensitivity analyses, Outcome 4 Subgrouped by ICS dose during exacerbation.
2.5
2.5. Analysis
Comparison 2 Primary outcome subgroup and sensitivity analyses, Outcome 5 Subgrouped by ICS fold increase.
2.6
2.6. Analysis
Comparison 2 Primary outcome subgroup and sensitivity analyses, Outcome 6 Sensitivity analysis: parallel‐group studies only.
2.7
2.7. Analysis
Comparison 2 Primary outcome subgroup and sensitivity analyses, Outcome 7 Sensitivity analysis: independently funded studies only.
See this image and copyright information in PMC

Update of

Comment in

References

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