Clinical Decisions

Mild Persistent Asthma — Polling Results

Laura E. Fredenburgh, M.D., Edward W. Campion, M.D., and Jeffrey M. Drazen, M.D.

N Engl J Med 2007; 357:179-180July 12, 2007

Article

Interactive Map

Clinical Decisions Polling Results by Country.

In mid-May, we introduced Clinical Decisions — a new interactive feature designed to help us understand how our readers would manage a given clinical case. Our opening case1 involved how to tailor the care of a 30-year-old woman with mild persistent asthma who, although only intermittently symptomatic while receiving treatment with inhaled beclomethasone at a dose of 160 μg twice a day, desired to cut back her treatment.

Among the three options offered to you, the most popular — receiving 2281 votes (37.5% of the 6085 votes cast) — was to switch the patient's treatment to a corticosteroid and a long-acting β₂-agonist, in a single inhaler to be used each morning, plus as-needed rescue albuterol. A close second, with 2273 votes (37.4% of the total votes cast), was to switch the patient's treatment such that beclomethasone and albuterol inhalers are used only when the patient has symptoms of asthma. The remaining option, to switch the treatment to an oral leukotriene-receptor antagonist plus as-needed rescue albuterol, received 1531 votes (25.2% of the total votes cast). The 6085 participants were from 113 countries and indicated that they were physicians (80%), other health professionals (12%), or students (8%). Detailed results are displayed according to country at www.nejm.org. The percentage of participants choosing a given option varied substantially when the responses were stratified according to the participants' locations, inferred from their Internet providers (Figure 1Figure 1Percentage of Participants Choosing Each Treatment Option for Mild Persistent Asthma.).

We received more than 340 comments from you, about 90% of which were posted at www.nejm.org (after being reviewed for appropriateness). Many suggested alternative management options, but there was no overwhelmingly favored choice. The comments showed how we as physicians use data to modify our thinking about treatment.

The majority of responders who chose to treat the patient with the as-needed use of inhaled beclomethasone and albuterol considered the patient's asthma to be well controlled, thus warranting step-down therapy. Many of you supported this treatment option because you felt that it would effectively control mild persistent asthma at a lower cumulative dose of inhaled corticosteroids, as shown by Papi et al.2 in the same issue of the Journal. Other justifications for this treatment choice were that it is associated with a high likelihood of compliance, is cost-effective, allows the patient a better sense of control over her disease, and addresses her concerns regarding side effects.

Those of you who opted to switch treatment to an oral leukotriene-receptor antagonist plus as-needed rescue albuterol felt that the frequency of the patient's symptoms necessitated daily antiinflammatory therapy and believed that the best such therapy that also minimized the side effects of corticosteroids was a leukotriene modifier. Although the study by the American Lung Association Asthma Clinical Research Centers3 in that issue of the Journal showed that patients whose treatment was switched to montelukast had an increased rate of treatment failure as compared with those switched to twice-daily fluticasone or nightly fluticasone plus salmeterol, many of you noted that the patient we described is willing to tolerate increased symptoms to avoid long-term side effects. In addition, many of you commented that leukotriene modifiers may be particularly effective, given the patient's atopy and exercise-induced symptoms.

Responders who preferred to switch the patient's treatment to a once-daily corticosteroid plus a long-acting β₂-agonist in a single inhaler believed that, given her frequent use of albuterol, particularly before exercise, she still required a daily long-term control medication. Many thought that the addition of a long-acting β₂-agonist would allow for a reduction in corticosteroid dose while providing better antiinflammatory therapy than a leukotriene-receptor antagonist, citing the study by the American Lung Association Asthma Clinical Research Centers. Several of you believed that this treatment option would decrease the need for rescue albuterol, would improve control of the patient's exercise-induced asthma, and would be associated with good compliance because of the once-daily dosing through a single inhaler.

It appears that although we as physicians use new data, we do not slavishly follow them. Rather, we integrate our experience with new knowledge to arrive at an evidence-directed approach. Most of you noted the importance of interacting with the patient about her desires with respect to treatment outcomes, as well as the importance of close clinical follow-up and the monitoring of spirometric data and exhaled levels of nitric oxide. Comments will remain posted at www.nejm.org, along with data on the voting results.

We judge this experiment a success and will use this interactive format in the future as new information accrues about the treatment of common conditions. We thank you for your input and look forward to hearing from you again soon about another challenging case.

References

References

1. 1

   Treatment of mild persistent asthma. N Engl J Med 2007;356:2096-2100
   Full Text | Web of Science | Medline

2. 2

   Papi A, Canonica GW, Maestrelli P, et al. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med 2007;356:2040-2052
   Full Text | Web of Science | Medline

3. 3

   The American Lung Association Asthma Clinical Research Centers. Randomized comparison of strategies for reducing treatment in mild persistent asthma. N Engl J Med 2007;356:2027-2039
   Full Text | Web of Science | Medline

Citing Articles (5)

Citing Articles

1. 1

   Charles K. Naspitz, Gerd J. Cropp. (2009) Recommendations for treatment of intermittent mild persistent asthma in children and adolescents. Pediatric Pulmonology 44:3, 205-208
   CrossRef

2. 2

   Alberto Papi. (2009) Treatment strategies in mild asthma. Current Opinion in Pulmonary Medicine 15:1, 29-34
   CrossRef

3. 3

   Piotr Kuna, Izabela Kuprys-Lipinska. (2008) Budesonide/formoterol for maintenance and reliever therapy: new quality in asthma management. Therapy 5:4, 495-512
   CrossRef

4. 4

   Watchara Boonsawat, Ludmila Goryachkina, Loretta Jacques, Lucy Frith. (2008) Combined Salmeterol/Fluticasone Propionate versus Fluticasone Propionate Alone in Mild Asthma. Clinical Drug Investigation 28:2, 101-111
   CrossRef

5. 5

   Drazen, Jeffrey M., Campion, Edward W., Curfman, Gregory D., Miller, Pamela W.Anderson, Kent R.Morrissey, Stephen, . (2007) Clinical Decisions. New England Journal of Medicine 356:20, 2093-2093
   Full Text