SELECTED ARTICLES FROM THE RECENT LITERATURE 2003

12/17/03

Long-acting beta agonists vs theophylline in the maintenance treatment of asthma

Summary
Theophylline (Theo) and long-acting beta agonists (LABA) are both bronchodilating drugs used in the treatment of asthma. Theo is used less frequently than formerly by most clinicians while LABA use by inhalation has increased greatly in recent years. But is there convincing evidence to support these usage patterns?

Shah et al of St. Michael's Hospital in Toronto, Canada updated an analysis of the Cochrane Database for the findings of comparisons of treatment with Theo and LABA in chronic asthma. They limited their analysis to randomized, controlled trials in children and adults with well documented chronic asthma in which sustained release Theo was compared with inhaled LABA (salmeterol or formoterol). In the studies meeting their criteria for review, symptom free nights were significantly more common during treatment with salmeterol, a LABA, than with Theo treatment. Also, the FEV-1 was improved significantly more during salmeterol than during Theo treatment. Formoterol, used in 2 studies, was reported to be as effective as Theo. There were significantly less frequent CNS and G-I adverse events during salmeterol than during Theo therapy. The authors concluded that LABA treatment is at least as effective as Theo therapy in reducing asthma symptoms, including nocturnal awakenings, while also improving FEV-1 to a greater extent than Theo. At the same time, fewer adverse effects were seen with LABA than with Theo treatment.

Reference
Cochrane Database Syst Rev 2003; CD 001281

Editor's Comments
The findings in this analysis reinforce my impression from my personal clinical experience plus the information obtained from colleagues who treat many asthmatics. However, one must mention the recent concerns about potentially serious adverse effects of chronic salmeterol use that prompted the FDA to require a "Black Box" warning in the description of this agent in package inserts and the PDR. During the recent START clinical trial project, a higher frequency of asthma mortality was reported in those using inhaled salmeterol than in those using placebo. Although the mechanisms underlying these very unfortunate adverse events has not been well clarified, one must proceed with considerable caution in using LABA chronically as monotherapy. I personally have used LABA only along with adequate doses of inhaled corticosteroids in chronic asthma treatment.

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