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Evidence-Based Review of the
Six Step Asthma Management Plan
 
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Evidence Based Review of the Six Step Asthma Management Plan
Home
Foreword
Background
Evidence
Literature
Results
Step 1
Step 2
Step 3
Step 4
Alternatives
Step 5
Step 6
Acknowledgments
Content created Feb 2000
Page updated Jul 2005

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Step 2: Achieve Best Lung Function

To obtain maximal reversal of airway inflammation and obstruction:

If FEV1 is less than 80% of the predicted reading or if the initial measurement increases by at least 15% after bronchodilator medication, intensive therapy to reduce airway inflammation and reverse airway obstruction is recommended.

Recommended treatment for adults with mild-moderate persistent asthma is inhaled corticosteroid (750/800 µg/day) plus B2 - agonists when required:

Inhaled steroid therapy in adults with an FEV1 < 80% 
A review of eight randomised controlled trials showed that inhaled corticosteroid therapy <800µg/day in subjects with an FEV1 <80% predicted, improved FEV1, PEF, symptoms, use of rescue medication, nocturnal waking, bronchial hyperresponsiveness and doctor-assessed efficacy. There was no significant change in plasma cortisol levels. Adverse events were assessed in six trials, one of which showed a significant increase in adverse events from corticosteroid use (Coughlan J & Wilson A, CAR) [LEVEL 2].

Inhaled steroid therapy in adults with an FEV1 >80%
Five randomised controlled trials studied the effect of inhaled corticosteroid therapy <800µg/day in subjects with an FEV1 >80% predicted. There was consistent improvement reported in PEF and bronchial hyperresponsiveness. Symptoms and use of rescue medications were improved in some trials but not others. There was little effect on FEV1 or night waking, no effect on the number of exacerbations and no reported increase in adverse events (Coughlan J & Wilson A, CAR) [LEVEL 2].

For more severe asthma a higher dose of inhaled steroid (750/800 - 2000µg/day) and/or oral corticosteroids may be required:

Inhaled steroid therapy in adults with an FEV1 <80%
LEVEL 2 evidence from six randomised controlled trials showed that inhaled corticosteroid therapy >800µg/day in subjects with an FEV1 <80% predicted improved FEV1, PEF, symptoms, use of rescue medication, nocturnal waking and doctor-assessed efficacy. None of the included studies measured bronchial hyperresponsiveness. There was no significant change in plasma cortisol levels or reported increase in adverse events (Coughlan J & Wilson A, CAR)[LEVEL 2].

Inhaled steroid therapy in adults with an FEV1 >80%
Seventeen randomised controlled trials studied the effect of inhaled corticosteroid therapy >800µg/day in subjects with an FEV1 >80% predicted. There was a consistent improvement PEF and bronchial hyperresponsiveness. Symptoms, FEV1, use of rescue medication, nocturnal waking and doctor-assessed efficacy were improved in some studies but not in others (Coughlan J & Wilson A, CAR) [LEVEL 2].

When FEV1 was not specified:
Adults using <800µg/day of inhaled corticosteroid
In 11 studies, an inhaled corticosteroid <800µg/day improved FEV1, PEF, hyperresponsiveness and doctor-assessed efficacy. There were no significant differences in plasma cortisol levels or adverse events. Use of rescue medication improved in nine of the 16 interventions that measured this outcome (Coughlan J & Wilson A, CAR) [LEVEL 2].

Adults using >800µg/day of inhaled corticosteroid
An inhaled corticosteroid >800µg/day improved FEV1, peak expiratory flow, symptoms, use of rescue medication, nocturnal waking and doctor-assessed efficacy. None of the included studies measured bronchial hyperresponsiveness. Only one study measured inflammatory markers, showing a significant reduction in eosinophil cationic protein and a non-significant reduction in blood eosinophils. There was no significant increase in plasma cortisol levels. Inhaled corticosteroids did not cause a significantly higher number of adverse events over placebo treatment (Coughlan J & Wilson A, CAR) [LEVEL 2].

Inhaled steroids should be reserved for those (children) who are either unresponsive to sodium cromoglycate or nedocromil sodium or those with features of severe persistent asthma at presentation.

Inhaled corticosteroids for children non-responsive to sodium cromoglycate
A single trial of poor methodological quality demonstrated that betamethasone valerate, compared with sodium cromoglycate, produced significant improvements in symptoms and morning and evening peak expiratory flow. Further trials are required to confirm this finding (Dakin C & Coughlan J, CAR) [LEVEL 2].