The woman described in the case vignette has well-controlled mild persistent asthma. She is an optimal candidate for the use of less medicine to control her disease, but before treatment can be reduced, it is important to be sure of the goals of asthma therapy. The Guidelines for the Diagnosis and Management of Asthma of the National Asthma Education and Prevention Program suggest that these goals include decreasing the frequency of troublesome symptoms (e.g., nighttime awakenings) to twice or fewer per month, decreasing the frequency of symptoms and the as-needed use of beta-agonists (except to prevent exercise-induced symptoms) to no more than 2 days per week, maintaining near-normal pulmonary function, reducing the frequency of recurrent exacerbations to no more than one per year, meeting the expectations of patients regarding asthma care, and minimizing or eliminating the adverse effects of therapy.7 In the patient in the vignette, the first five goals have been met, but has the sixth?
The patient's current treatment regimen results in the use of the equivalent of approximately 100 mg of beclomethasone per year. (All doses mentioned here reflect adjustment for equivalence among different preparations of inhaled corticosteroids, according to standards of the National Asthma Education and Prevention Program.) The articles by the American Lung Association Asthma Clinical Research Centers1 and Papi et al.2 in this issue of the Journal suggest several potential means of reducing the patient's use of inhaled corticosteroids. Although there are other possibilities, this feature focuses on three treatments: the as-needed use of a combination of inhaled corticosteroids and short-acting beta-agonists (resulting in a dose equivalent to approximately 37 mg of beclomethasone per year), the once-daily use of a combination of inhaled corticosteroids and long-acting beta-agonists (resulting in a dose equivalent to approximately 45 mg of beclomethasone per year), and the daily use of a leukotriene modifier.
How is one to choose among the three options? In this case, the patient's expressed desires and her clinical history should guide us. She would prefer less therapy and fewer long-term side effects. Before the publication of the articles that appear in this issue of the Journal, I would have surmised from the patient's history of few to no previous exacerbations in the absence of controller therapy that it would be safe to reduce the doses of her medications. Furthermore, the articles provide evidence that, regardless of the clinical history, the current level of control of the patient's asthma puts her at minimal risk for serious asthma symptoms with any of the three treatment choices. Nonetheless, she may notice some mild differences in the control of symptoms among the three regimens. She is willing, however, to tolerate some increase in symptoms, should they occur.
She is also concerned about side effects. Although the effects of long-term inhaled corticosteroids are small, if the patient receives the current dose for 25 years, her risk of fracture may be doubled.8 The two treatments involving corticosteroids and beta-agonists would reduce the dose of inhaled corticosteroids by two thirds as compared with her current therapy, but the relationship between bone loss and the dose of inhaled corticosteroids varies widely among patients.8
The patient may appear to be a candidate for as-needed controller therapy only,4 but her symptoms with exercise caused her to seek therapy 5 years ago. Thus, it is unlikely that she will be satisfied with no therapy at all. Leukotriene modifiers address this problem. They reduce the degree of exercise-induced bronchospasm without tachyphylaxis9 or concerns related to the use of long-acting beta-agonists alone.10 If her symptoms are intolerable or include frequent exacerbations (both highly unlikely, given her history), the two treatments involving corticosteroids and beta-agonists could be considered. However, the regular use of a leukotriene modifier addresses this patient's concerns about the side effects of medications. It should also decrease her most bothersome symptom: exercise-induced bronchospasm. It's just what the patient ordered; the physician would do well to heed her call.
Dr. Israel reports serving as a consultant for Asthmatx, Critical Therapeutics, Genentech, Merck, Protein Design Labs, Schering-Plough, and Teva Specialty Pharmaceuticals; receiving lecture fees from Genentech and Merck; and receiving grant support from Boehringer Ingelheim, Centocor, and Merck. No other potential conflict of interest relevant to this article was reported.
From the Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston.
