Researchers from the UK investigate whether very high doses of inhaled steroids are effective for preventing a severe impending asthma attack.

Asthma affects approximately 300 million people worldwide, making it one of the most common chronic diseases today. Asthma attacks are scary for patients and sometimes fatal. Patients often use inhaled glucocorticoids for self-management of asthma which improves asthma control. However, experts disagree about what dose of inhaled glucocorticoids should be used to control and prevent an acute asthma attack.

Previous studies suggest doubling glucocorticoids may prevent asthma attacks

Some guidelines suggest that doubling the dose of inhaled glucocorticoids is effective at preventing asthma attacks. Other studies suggest that an increased dose does not reduce the odds of hospitalization, oral glucocorticoid use, or shorten recovery time. Researchers in the UK conducted a non-blinded randomized controlled study to investigate whether quadrupling the currently recommended dose would be beneficial. They recently published their results in the New England Journal of Medicine.

The current study aimed to discover if a temporary four-fold increase in inhaled glucocorticoids would reduce the need for oral glucocorticoids or asthma-related emergency doctor visits. The study included 1,871 adults and teens with asthma who were already taking inhaled glucocorticoids and had had at least one asthma attack in the previous year. The participants were randomly divided into two groups. One group had a self-management plan that included a four-fold increase in inhaled glucocorticoids (the quadrupling group). The participants used this higher dose temporarily when they were having trouble controlling their asthma. The other group had the same self-management plan but without the four-fold increase in glucocorticoid dose (the non-quadrupling group).

Quadrupling dose resulted in fewer hospitalizations

The participants in the quadrupling group had fewer asthma attacks during the 12-month study compared to those in the non-quadrupling group (45% vs. 52%, respectively). The average time to the first severe asthma attack was also significantly longer in the quadrupling group. Additionally, the quadrupling group reported fewer asthma-related hospitalizations than the non-quadrupling group (3 vs. 18). The development of thrush, an oral yeast infection, was a common negative side effect for the patients in the quadrupling group.

Although the results were not as convincing as the researchers had initially hoped, they nonetheless believe that this study supports a temporary quadrupling of inhaled glucocorticoid dose for preventing asthma attacks. There are many factors to consider, including the fact that this study was not blinded, so it may be subject to bias. Additionally, although this study did not report more serious side effects with the quadrupling group than in the standard condition, more research will be needed to confirm the safety of using such high doses over the long-term.

Written by Cindi A. Hoover, Ph.D.

Reference: McKeever T, Mortimer K, Wilson A et al. Quadrupling inhaled glucocorticoid dose to abort asthma exacerbations. N Engl J Med 2018; 378:902-10.

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