SELECTED ARTICLES FROM THE RECENT LITERATURE 2003

11/25/03

Rapid effects of inhaled corticosteroids on nocturnal asthma

Summary
Inhaled corticosteroids (ICS) are the manor controller medication approach in the management of chronic persistent asthma. It has been generally thought that ICS treatment takes at least several days to be effective with no rapid effects seen. However, Frezza et al of the Univ of S. Paolo Medical School in Brazil have reported a relatively rapid effect of ICS on nocturnal asthma worsening. They investigated the effects of a single dose of either beclomethasone 1000 mcg or fluticasone 1000 mcg vs placebo given at 4 PM to 10 individuals with moderate persistent asthma and reported nocturnal worsening who had not been previously treated with oral steroids or ICS. During observation in the laboratory they found that the FEV-1 decreased 0.65L by 4 AM (when compared to the FEV-1 at the previous 4 PM) following placebo treatment. In comparison, the FEV-1 decreased: 1) only 0.02L following fluticasone treatment (p=0.019 vs placebo) and2) 0.23L following beclomethasone administration (p=0.048 vs placebo). The authors concluded that ICS can have a rapid effect in decreasing the nocturnal worsening of asthma.

Reference
Thorax 2003; 58:632-3

Editor's Comments
Although the size of the study group was small in this project, the findings are highly suggestive of an early effect of ICS, particularly fluticasone. However, the doses used are really not that relevant to that generally used chronically in most asthmatics followed in clinical practice at this time. Beclomethasone is being used less and less because of the availability of newer ICS agents which are much less likely to be bioavailable systemically when swallowed. The 1000 mcg dose of fluticasone is much higher than in general use for chronic therapy because of potential for systemic steroid adverse effects of this high dose after partial systemic absorption from the lungs. When a dose this high is used it is generally limited to initiation of therapy (and subsequent tapering as the patient improves). However, this dose could lead to rapid reduction of nocturnal asthma flares.

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