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previous  next Provided by/avec le support de :     Box 34        S-221 00 Lund Sweden ARLS information : Myrna Mansson Get the paper version from your local Marketing representative. Find the address ont the net at http://www.astrazeneca.com/Marketing-worldwide AstraZeneca Respiratory Literature Service N°4   1997 (see N° 2 1997 also N° 3 1997 and N° 5 1997) For many years, AstraZeneca Draco laboratories have brought to the asthmolgist community an excellent "Respiratory Literature Service" (ARLS) with an alert to new references, selected summaries and comments by a group of experts. In 1997, AstraZeneca is extending this concrete service with Asmanet in order to take advantage of the Internet capabilities. The following comments have been edited ( HTML format) to smooth the reading with hypertext links to integrate the comment in the Asmanet server and the worldwide distributed library on asthma, such as : abstract of the commented paper, references as seen on Medline and others, author's e-mail ...   Title Authors Journal Reviewer 1 Inhaled steroids and the risk of hospitalization for asthma Donahue J.G., Weiss S.T., Livingston J.M., et al   JAMA 1997 Professor Duncan Geddes 2 A controlled trial of immunotherapy for asthma in allergic children Adkinson Jr N.F., Eggleston P.A., Goldstein E.O., et al N Engl J Med 1997 Professor Duncan Geddes 3 Effectiveness of the leukotriene receptor antagonist zafirlukast for mild-to-moderate asthma: a randomized, double-blind, placebo-controlled trial Suissa S., Dennis R., Ernst P., et al Ann Intern Med 1997 Professor Duncan Geddes 4 Impact of nurse-led home management training programme in children admitted to hospital with acute asthma: a ramdomised controlled study. Madge P., McColl J., Paton J. Thorax 1997 Professor Philippe Godard 5 A controlled trial of immunotherapy for asthma in allergic children. Adkinson Jr N.F., Eggleston P.A., Eney D.,et al. N Engl J Med 1997 Professor Philippe Godard 6 Inhaled steroids and the risk of hospitalization for asthma Donahue J.G., Weiss S.T., Livingston J.M., et al.   JAMA, 1997 Professor Philippe Godard 7 Montelukast causes prolonged, potent leukotriene D4-receptor antagonism in the airways of patients with asthma De Lepeleire I., Reiss T.F., Rochette F., et al Clin Pharmacol Ther 1997 Professor John H. Toogood 8 A controlled trial of immunotherapy for asthma in allergic children Adkinson N.F., Eggleston P.A., Goldstein E.O., et al N Engl J Med 1997 Professor John H. Toogood 9 The clinical efficacy of combination nebulized anticholinergic and adrenergic bronchodilators vs nebulized adrenergic bronchodilator in acute asthma FitzGerald J.M., Grunfeld A. Chest 1997 Ass Prof Leif Rosenhall 10 Adrenal suppression with chronic dosing of fluticasone propionate compared with budesonide in adult astmatic patients Clark D.J, Lipworth B.J. Thorax 1997 Ass Prof Leif Rosenhall 11 A controlled trial of immunotherapy for asthma in allergic children Adkinson F.N., Eggleston P.A. N Engl J Med 1997 Ass Prof Leif Rosenhall 12 Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study Madge P., McColl J., Paton J. Thorax 1997 Ass Prof Leif Rosenhall AstraZeneca Draco laboratories is also supporting the European Federation of Asthma and Allergy Associations which can be seen at http://www.efanet.org/ Access for abstracts to Medline through Healthgate (http://www.healthgate.com/HealthGate/MEDLINE/search.shtml ) or through HealthWorld Medline Search (http://www.healthy.net/library/search/medline.htm ): direct access to the abstract whenever it's available is not possible. You have to perform a "search" using the search engine (and be exposed to the local advertiser banner which sort-of pays for the free access). You will then go through the following steps : Select the names of the first two authors (or part of the title) and do a "copy" (ctrl C on a PC under Windows) so that you will have the search key at hand. Click on the link in order to get the HealthGate/HealthWorld search home page. Paste the search key (ctrl V) into the search window displayed on your screen and perform the search. The search engine will send you back the list of papers with those two authors. HealthWorld search engine will give you related papers if you select it by the title. You will then select the link which you want if the paper is known and click on the link to get the abstract. ...

All published asthma guidelines introduce inhaled steroids early in management. There is however little community based evidence to support this recommendation. This study provides a mass of interesting statistics and welcome support for such consensus guidelines.

Records form a health maintenance organisation in Eastern Massachusetts were searched for the diagnosis of asthma and 17,000 asthmatics were found in a population of 300,000. The medication prescribed was then compared with the rate of hospitalization whilst adjusting for asthma severity. Over half were receiving b-agonists, about one-quarter inhaled steroids, around 10% theophylline and 5% cromolyn. Surprisingly one-third of the subjects had received a prescription for oral corticosteroids.

Inhaled steroids halved the risk of hospitalization in each severity group while cromolyn reduced hospitalization by about one-third in children with no significant change in adults. These data provide strong support for the early prescription of inhaled corticosteroids in a large community sample. It is reassuring to have controlled trial data confirmed in well designed community studies.

Title (1): Inhaled steroids and the risk of hospitalization for asthma. (partial abstract from http://www.healthy.net/library/search/medline.htm )

Author : Donahue JG; Weiss ST; Livingston JM; Goetsch MA; Greineder DK; Platt R
Address : Channing Laboratory, Boston, MA, USA. Jim.Donhaue (at) channing.harvard.edu
Source : JAMA, 277(11):887-91 1997 Mar 19
A

bstract
OBJECTIVE: To determine if anti-inflammatory treatment for asthma reduces the risk of asthma hospitalization.
DESIGN: Retrospective cohort study.
SETTING: A health maintenance organization (HMO) in eastern Massachusetts.
PARTICIPANTS: Members of the HMO who were identified during the period October 1991 through September 1994 as having a diagnosis of asthma using a computerized
medical record system.
MAIN OUTCOME: Hospitalization for asthma.
RESULTS: Of the 16941 eligible persons, 742 (4.4%) were hospitalized for asthma. The overall relative risk (RR) of hospitalization among those who received inhaled steroids was 0.5 (95% confidence interval [CI], 0.4-0.6) after adjustment for beta-agonist dispensing. Additional adjustment for age, race, other asthma medications, and amount and type of ambulatory care for asthma did not substantially affect the inverse relationship between use of inhaled steroids and hospitalization. Cromolyn was similarly associated with reduced risk, especially among children (RR,0.8; 95% CI, 0.7-0.9). In contrast, increasing beta-agonist use was associated with increasing hospitalization risk even after adjustment for other factors and medications. The steroid-associated protection was most marked among individuals who received the largest amount of beta-agonist. ....

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

This is a well-conducted, double-blind, placebo-controlled trial of multiple allergen immunotherapy in 121 allergic children with moderate to severe perennial asthma. Subcutaneous injections of a mixture of up to 7 aeroallergens were given for eighteen months or longer and compared with placebo and no significant differences were found.

These negative findings once again question the role of immunotherapy in the routine treatment of allergic asthma. Not surprisingly this paper was greeted with orchestrated howls of dismay from allergists and immunotherapists. The paper has been critcised for not including appropriate antigens (e.g. cockroach) and for judging a treatment in the artificial setting of a randomised controlled trial. While this study does not address the role of immunotherapy for the treatment of allergic disease associated with a single specific allergen it provides strong evidence that such treatment is usually unnecessary in the context of the more common multiple allergic asthma in children.

This remains a useful and valid study and its critics must provide contrary evidence if they wish to refute its findings.

Title (2) : A controlled trial of immunotherapy for asthma in allergic children. (partial abstract from http://www.healthy.net/library/search/medline.htm )

Author : Adkinson NF Jr; Eggleston PA; Eney D; Goldstein EO; Schuberth KC; Bacon JR; Hamilton RG; Weiss ME; Arshad H; Meinert CL; Tonascia J; Wheeler B
Address : Asthma and Allergy Center and the Department of Medicine, Johns Hopkins University School of Medicine, MD, USA.
Source : N Engl J Med, 336(5):324-31 1997 Jan 30

Abstract
BACKGROUND: Injections of allergens are widely prescribed for patients with asthma, but little is known about the effectiveness of immunotherapy.
METHODS: We conducted a double-blind, placebo-controlled trial of multiple-allergen immunotherapy in 121 allergic children with moderate-to-severe, perennial asthma. The children, who required daily medication for their asthma, were randomly assigned to receive subcutaneous injections of either a mixture of up to seven aeroallergen extracts or a placebo. Maintenance injections were continued for 18 months or longer. Medications were adjusted every two to three weeks on the basis of peak flow rates and symptoms. The principal outcome was the daily medication score. Bronchial sensitivity to methacholine (the concentration provoking a 20 percent decrease in the forced expiratory volume in one second [PC20]) was measured twice yearly.
RESULTS: The median medication score declined from 5.4 to 4.9 in the immunotherapy group (P<0.001) and from 5.2 to 5.0 in the placebo group (P<0.001), but there was no significant difference between the groups (P>0.6). The number of days on which oral corticosteroids were used was similar in the two groups. .... ...

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

Evidence is accumulating that leukotriene antagonists are effective treatments for asthma. The size of the benefit is however unclear and it is not known whether such treatment is cost effective or where these drugs should be placed in relation to inhaled corticosteroids.

In this study 146 patients with mild-to-moderate asthma (b-agonists only) were randomised to receive Zafirlukast or placebo prior to assessment of asthma, social outcome and healthcare resource consumption over a 13 week period.

Zafirlukast treated patients had twice as many days free of symptoms and without b-agonist use when compared with placebo but there was no difference in freedom from asthma-related limitations or sleep disturbance. At the same time healthcare contacts and school/work absenteeism were reduced by half.

Overall this study provides further evidence that this class of drugs has an effect against asthma and shows that there are symptomatic and also healthcare resource benefits from its use. However, cost and efficacy comparisons with inhaled steroids will be needed before the role of leukotriene antagonists can be defined.

Title (3): Effectiveness of the leukotriene receptor antagonist zafirlukast for mild-to-moderate asthma: a randomized, double-blind, placebo-controlled trial. (partial abstract from http://www.healthy.net/library/search/medline.htm )

Author : Suissa S; Dennis R; Ernst P; Sheehy O; Wood-Dauphinee S
Address : Royal Victoria Hospital, Montreal, Quebec, Canada.
Source: Ann Intern Med, 126(3):177-83 1997 Feb 1

Abstract
BACKGROUND: The increasing costs of managing asthma are due in part to the introduction of new medications, such as leukotriene receptor antagonists. These antagonists interfere with the action of leukotrienes, which are implicated in bronchoconstriction and the formation of airway edema in patients with asthma. Leukotriene receptor antagonists must be shown to be clinically and economically effective for their clinical use to be justified.

OBJECTIVE: To assess the clinical and economic effectiveness of zafirlukast, a leukotriene receptor antagonist, in patients with mild-to-moderate asthma who might benefit from regular anti-inflammatory therapy. DESIGN: Randomized, double-blind, multicenter, placebo-controlled trial. SETTING: 28 outpatient clinics.

PATIENTS: 146 patients with mild-to-moderate asthma who were 12 years of age or older, had not smoked cigarettes in the previous 6 months, had a smoking history of less than 10 pack-years, had an FEV1 at least 55% of the predicted value with no upper limit, had demonstrated bronchial hyperresponsiveness, and were symptomatic during the 7-day run-in period. All patients were seen every 2 to 3 weeks for 13 weeks.

INTERVENTION: 103 patients received zafirlukast (20 mg twice daily), and 43 patients received placebo (twice daily). All patients received inhaled beta-agonists as needed.

MEASUREMENTS: Data were obtained from medical examinations, patient questionnaires, and daily diaries. The clinical effectiveness outcomes were days per month without asthma symptoms, limitation of activity, use of beta-agonists, sleep disturbance, and episodes of asthma (the latter was a composite measure made up of the first four outcomes plus the occurrence of adverse events). The economic effectiveness outcomes were frequency and type of unscheduled health care contacts, use of beta-agonist inhalers, consumption of nonasthma medications, and days of absence from work or school.

RESULTS: The zafirlukast group ...

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

Severe asthma is a continuous challenge for patients and - as underlined by the authors of this interesting study - 21% of asthmatic children are re-admitted after a first admission in an ICU. For this reason, self-management programmes are needed, in addition to optimal medical treatment. I was personally surprised to learn that there are conflicting results about the efficacy of nurse-led home management.

In this particular study the results indicate that nurse-led home management, administered during hospital admission is helpful. Since this kind of procedure is expensive and time-consuming, the authors introduced the programme as a randomised controlled trial to justify (or not) its continued use. The study has been well conducted. However, as usual I would like to add some comments.

-The outcome was the re-admission rate; a Kaplan Meier curve has been drawn. But there was no cost effectiveness analysis.

-The follow-up period ranges from 2 to 14 months. There is no analysis of this length of time, first in term of loss of effectiveness of the programme, or second in terms of a recommendation for its optimal duration. In other words is it really neccessary to use this approach (nurse-led home management) for more than one or two years?

-It would also have been interesting to know whether the nurse gave some advice about allergy and home pollution.

-In the discussion, the authors state that they did not monitor how frequently couses of oral steroids were taken. Some years ago, I initiated a follow-up study using Minitel (the French grand father of the Internet) to provide education on asthma management. I observed that some patients used the system "very well" but they took this opportunity to decrease the number of visits (good thing), but the total oral steroid intake increased. I decided to stop this method.

In conclusion, these studies are valuable but further information is required before such programmes are introduced routinely to clinical practice.

Title (4): Impact of nurse-led home management training programme in children admitted to hospital with acute asthma: a ramdomised controlled study.. (partial abstract from http://www.healthy.net/library/search/medline.htm )

Author : Madge P; McColl J; Paton J
Address : Department of Child Health, Royal Hospital for Sick Children, Yorkhill NHS Trust, Glasgow, UK.
Source : Thorax, 52(3):223-8 1997 Mar

Abstract
BACKGROUND: Re-admissions to hospital in childhood asthma are common with studies reporting that 25% or more of children will be re-admitted within a year. There is a need for strategies to reduce re-admissions. METHODS: A prospective randomised control study of an asthma home management training programme was performed in children aged two years or over admitted with acute asthma. Two hundred and one children were randomised at admission to either an intervention group (n = 96) which received the teaching programme or a control group (n = 105). A nurse-led teaching programme used the current attack as a model for the management of future attacks and included discussion, written information, subsequent follow up and telephone advice aimed at developing and reinforcing individualised asthma management plans. Parents were also provided with a course of oral steroids and guidance on when to start them.

RESULTS: The groups were similar in degree of social deprivation, length of stay, number of previous admissions, acute asthma treatment, and asthma treatment at discharge. Subsequent re-admissions were significantly reduced in the intervention group from 25% to 8% in individual follow up periods that ranged from two to 14 months (chi 2 = 9.63; p = 0.002). .....

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Bronchial asthma is a complex disorder; it´s a multifactorial syndrome and all the components have to be taken into account for a good result. Immunotherapy has been used for a long time in allergic asthma and, even if substantial progress has been made recently, the issue of efficacy remains controversial. This paper is a negative one.

With regard to this study my aim is to take the opportunity highlight some principles which I think very important:

- The diagnosis of allergy is easily accomplished by using a skin prick test and RAST. But the real problem is to evaluate the responsibility of any allergen in the severity of asthma. This has to be determined before a decision for or against immunotherapy is taken.

- Evalution of indoor pollution has to be carried out carefully. This requires one or several visits to the patient´s home. This has been done in this study. However, although it is indicated that house dust was sampled, the results are not provided and, moreover, the study findings have not been analysed in this context.

- It has been shown that endotoxin levels in house dust may be more important than the mite content itself. This must not be forgotten.

-Control of indoor pollution has been conducted in this study. However, the effect of this approach was not measured. This should be done in the future.

-The discussion in the paper is very interesting and should be read carefully, as it provides several explanations to try to explain the negative results.

-An ancillary benefit of immunnotherapy could be an increased compliance to pharmacotherapy and a better understanding of allergy and asthma. Indeed at each injection of the allergen, the doctor - and his patient - had the opportunity to review the management of the disease.

Immunotherapy could be a good treatment for allergic asthma in children. However we have to increase our knowledge in order to produce more standardised allergens, to select optimal candidates for such a treatment, and take into account all the facets of this procedure.

Title (5): A controlled trial of immunotherapy for asthma in allergic children. (partial abstract from http://www.healthy.net/library/search/medline.htm )

same as above Title 2

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

A European chest physician might find this study surprising. Indeed, the use of inhaled steroids is more common here than in the US and drug dosages are higher. Futhermore, it is well established in clinical practice in Europe that treatment with inhaled steroids decreases the number of asthma exacerbations.

The main finding of this paper is that inhaled steroids are associated with a 50% decrease in the risk of hospitalization. However, the finding that there was no dose response relationship is very surprising. The fact that the study was carried out using a retrospective analysis may account for this unexpected finding, and is one reason why a prospective study might have been better.

Health maintenance organisations (HMO) are developing in Europe which may facilitate conducting similar retrospective studies here. As a generanl point, more reliable results could be obtained if the records are kept better.

Title (6): Inhaled steroids and the risk of hospitalization for asthma. (partial abstract from http://www.healthy.net/library/search/medline.htm )

same as above Title 1

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

This study demonstrates that oral Montelukast can inhibit the bronchospastic response of asthmatic patients to inhaled leukotriene.

Other published data indicate this leukotriene receptor antagonist is free from the troublesome drug-drug interactions and hepatotoxicity that complicate the use of alternative leukotriene receptor antagonists such as Zafirlukast, or the inhibitor of leukotriene biosynthesis, Zileuton.

Montelukast offers a safe and modestly effective, non-steroidal, oral alternative to low dose inhaled steroid therapy in patients with mild asthma. It is not yet known whether Montelukast treatment can improve airways hyperresponsiveness or prevent the progression over time of variable obstructive impairment to chronic airflow limitation.

Title (7): Montelukast causes prolonged, potent leukotriene D4-receptor antagonism in the airways of patients with asthma. (partial abstract below from http://www.healthy.net/library/search/medline.htm )

Author : De Lepeleire I; Reiss TF; Rochette F; Botto A; Zhang J; Kundu S; Decramer M
Address : Merck Research Laboratories, Brussels.
Source : Clin Pharmacol Ther, 61(1):83-92 1997 Jan

Abstract
Montelukast, a new specific oral cysteinyl LT3-receptor antagonist was evaluated for its activity in attenuating inhaled leukotriene D4 (LTD4) bronchoconstriction in patients with asthma. In two double-blind, placebo-controlled, randomized crossover studies, patients with mild asthma (forced expiratory volume in 1 second [FEV1] > or = 70%) were studied. In trial A, LTD4 challenge began 4 hours (peak plasma concentration) after a single dose of placebo or 5, 20, 100, and 250 mg montelukast. In trial B, and LTD4 challenge was started 20 hours after administration of placebo, 40 mg montelukast, or 200 mg montelukast. During each challenge, twofold increasing concentrations of LTD4 were inhaled until specific airways conductance (sGaw) decreased by at least 50% (PC50) or the highest concentration of LTD4 was inhaled. In trial A with all doses and in trial B with the 200 mg dose, bronchoconstriction was attenuated (50% fall in sGaw was not observed) up to the highest dose of LTD4 administered. In trial B, during the 40 mg period, only two of six patients exhibited a 50% fall in sGaw; PC50 ratios (montelukast 40 mg/placebo) were 18 and 45 in these two patients. These results indicate that montelukast is a highly potent and long-lasting antagonist of LTD4-induced bronchoconstriction in patients with asthma.

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

The merits of specific immunotherapy for allergic asthma have been widely debated in recent years (1, 2, 3, 4, 5, 6, 7). Overall, the evidence for its clinical utility remains equivocal at best.

Canadian guidelines currently recommend limiting its use to selected patients with allergic asthma that has proven suboptimally responsive to medication and allergen avoidance regimens (8).

Currently, less than 3% of the adults attending our academically based Allergy Clinic, a tertiary health care facility, receive such treatment. This reflects a marked decline since the introduction of more efficient pharmaceutical treatment for asthma.

Reference:

1. Norman P.S.
Is there a role for immunotherapy in the treatment of asthma?
Am J Respir Crit Care Med 1996; 154: 1225-1228

2. Barnes P.J.
Is immunotherapy for asthma worthwhile?
N Engl J Med 1996; 334: 531-532

3.Multiple authors.
Correspondence re ragweed immunotherapy for asthma.
N Engl J Med 1996; 335: 203-206

4.Creticos P.S., Reed C.E., Norman P.S., et al
Ragweed immunotherapy in adult asthma.
N Engl J Med 1996; 334: 501-506

5.Abramson M.J., Puy R.M., Weiner J.M.
Is allergen immunotherapy effective in asthma? A meta-analysis of randomized controlled asthma trials.
Am J Respir Crit Care Med 1995; 151: 969-974

6.Platts-Mills T.A.
Allergen-specific treatment for asthma.
Am Rev Respir Dis 1993; 148: 553-555

7.Haugaard L., Dahl R.
Immunotherapy in patients allergic to cat and dog dander.
Allergy 1992; 47: 249-254

8. Canadian Society of Allergy and Clinical Immunology.
Guidelines for the use of allergen immunotherapy.
Can Med Assoc J 1995; 152: 1413-1419

Title (8): A controlled trial of immunotherapy for asthma in allergic children. (partial abstract from http://www.healthy.net/library/search/medline.htm )

same as above Title 2

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

In a very large, well performed and important Canadian multicenter study the use of 3 mg salbutamol alone was compared with the same dose of salbutamol in combination with 0,5 mg ipratropium bromide in patients with acute asthma. The inclusion criteria were very strict to ensure that no patients with COPD were included.

The result that there is no significant benefit of routinely adding ipratropium bromide to inhaled b2-agonists when treating acute asthma is very convincing particulary when considering that the dose of salbutamol used was rather low (3 mg). Of course all patients also recieved a sufficient dose of systemic steroids.

Ipratropium bromide should mainly be used when treating COPD alone or when it is present together with asthma.

Title (9): The clinical efficacy of combination nebulized anticholinergic and adrenergic bronchodilators vs nebulized adrenergic bronchodilator in acute asthma. Canadian Combivent Study Group. (partial abstract from http://www.healthy.net/library/search/medline.htm )

Author : FitzGerald JM; Grunfeld A; Pare PD; Levy RD; Newhouse MT; Hodder R; Chapman KR
Address : Respiratory Clinic, Vancouver Hospital, BC. Canada.
Source : Chest, 111(2):311-5 1997 Feb

Abstract
The role of ipratropium bromide as adjunct therapy to beta-agonists in acute asthma is uncertain. We therefore decided to compare the use of 3 mg of salbutamol sulfate alone vs 3 mg salbutamol sulfate with 0.5 mg ipratropium bromide in patients with acute asthma. Patients presenting with acute asthma and an FEV1 less than 70% predicted were randomized to a single combination treatment vs salbutamol alone. All patients received supplemental oxygen and methylpred-nisolone, 125 mg, IV. Baseline measurements were repeated at 45 and 90 min and these included spirometry, oximetry, and vital signs. A total of 952 patients were screened of whom 342 patients were deemed eligible and were randomized in two groups of 171 patients. The mean (SE) age was 30 years (0.9) vs 29 years (0.7), women, 103 (60.2%) vs 110 (64%), 81 (47.4%) never-smoked vs 83 (48.5%), and duration of asthma in years 16.0 (0.8) vs 16.6 (0.8) were no different in the combination vs salbutamol alone group, respectively. Likewise, there was no significant difference in asthma therapy received in the 24 h prior to presentation; most notably, 151 (88.3%) vs 153 (89.5%) received inhaled beta-agonists in that period. Baseline FEV1 was 1.62 L (0.05 L) vs 1.53 L (0.03 L), and median time to treatment being received was no different between both groups. ...

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

This very important study will be discussed and quoted by many interested in the modern treatment of asthma with inhaled steroids.

In a very convincing way fluticasone was shown to give a signficantly more pronounced adrenal suppression than budesonide per mg given dose. Even if fluticasone per mg is more potent than budesonide as an antiasthmatic drug, the risk for systemic side effects must be seriously considered when the drugs are used for long term therapy.

The susceptibility for adrenal suppression varies from one individual to another and so the saftey margins need to be wide. The clinical effects of adrenal suppression are difficult to diagnose and may easily be overlooked. However, we know from the past when most severe asthmatics were on systematic steroids how dangerous and important adrenal suppression can be both in stress situations and in the control of the asthma. In fact, nowadays, asthmatics are much better controlled when treated with inhaled steroids than they were when they got systemic steroids. This is probably due to an intact adrenal function.

Therefore we must avoid inhaled steroids in doses which may give rise to significant adrenal suppression.

Title (10): Adrenal suppression with chronic dosing of fluticasone propionate compared with budesonide in adult astmatic patients. (partial abstract from http://www.healthy.net/library/search/medline.htm )

Author : Clark DJ; Lipworth BJ
Address : Department of Clinical Pharmacology, Ninewells Hospital and Medical School, University of Dundee, UK.
Source : Thorax, 52(1):55-8 1997 Jan

Abstract
BACKGROUND: In a previous single dosing comparison between fluticasone propionate and budesonide differences in cortisol levels measured at 08.00 hours were observed at doses in excess of 1000 micrograms. The aim of this study was to compare the adrenal suppression caused by chronic twice daily dosing with inhaled fluticasone propionate (FP) and budesonide (B) given on a microgram equivalent basis by metered dose inhaler to asthmatic patients. METHODS: Twelve stable asthmatic patients of mean age 29.7 years with forced expiratory volume in one second (FEV1) 89.0% predicted and mid forced expiratory flow (FEF25-75) 58.9% predicted, on 400 micrograms/day or less of inhaled corticosteroid, were studied in a double blind, placebo controlled, crossover design comparing inhaled budesonide and fluticasone propionate in doses of 250 micrograms, 500 micrograms, and 1000 micrograms twice daily. Each dose was given at 08.00 hours and 22.00 hours for four days by metered dose inhaler with mouth rinsing. Measurements were made of overnight urinary cortisol excretion and plasma cortisol levels at 08.00 hours, 10 hours after the eighth dose. RESULTS: The plasma cortisol levels (nmol/ l) at 08.00 hours showed that fluticasone propionate produced lower cortisol levels than budesonide at all three dose levels: .....

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

Sometimes when you read a scientific paper you have to think about the amount of work and effort which must lie behind the report. This is such an occasion and you really feel grateful and happy that the study has been performed.

For two years 350 allergic children with perennial asthma were treated either with immunotherapy or placebo. The two groups were otherwise very similar and their asthma was treated optimally with drugs. The immunotherapy was of no benefit for the outcome of asthma, and should not be advocated for this indication!

On the other hand the authors strongly stress that immunotherapy may be used for other indications.

The study also demonstrates the good prognosis of childhood asthma as almost 30% in both groups had either a complete or a partial remission during the study period.

Title (11): A controlled trial of immunotherapy for asthma in allergic children. (partial abstract from http://www.healthy.net/library/search/medline.htm )

same as above Title 2

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

The importance of patient education in the treatment of asthma can never be stressed too much.

In this rather simple but very thorough study it is clearly shown that nurse led education of parents whose child had been admitted because of an asthma attack is very effective. The re-admission rate was 8 % in the intervention group compared to 25% in the control group. Information and education really are cost-effective.

I thought that the study was very thoroughly done, but that perhaps the statistical analysis was overwhelming. The results are so clear that the battery of statistical tests could have been somewhat reduced.

Title (12): Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. (partial abstract from http://www.healthy.net/library/search/medline.htm )

same as above Title 4

... for the complete abstract, please enquire http://www.healthy.net/library/search/medline.htm

.AsmanetCongrès Conçue et réalisée par: Michel Godard (at) Top
Date de création: 1997 - Dernière mise à jour: 17/06/99
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