Chest
Volume 113, Issue 4, April 1998, Pages 964-967
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Clinical Investigations: Asthma
Is Normal Bronchial Responsiveness in Asthmatics a Reliable Index for Withdrawing Inhaled Corticosteroid Treatment

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Study objective

Inhaled corticosteroid (ICS) treatment is first-line maintenance therapy in bronchial asthma. However, it is not clear whether and when ICS treatment can be withdrawn. The aim of this open study was to assess whether normalization of bronchial responsiveness could be used as a reliable index to assess the opportunity of ICS treatment withdrawal.

Design

Open study at two different points in time.

Setting

Outpatient pulmonary clinic.

Patients

Eighteen asthmatic subjects.

Measurements and results

ICS therapy was withdrawn in subjects treated with beclomethasone dipropionate, at the maintenance dose of 889±246 μg/d for >3 months. Upon recruitment, all subjects were asymptomatic, had FFV1 >70% of predicted value, and were in treatment with β2-agonists on an as-needed basis. Eight subjects (group 1) had normal bronchial responsiveness (methacholine provocative dose causing a 20% fall in FEV1 [PD20] >2,000 μg) and 10 subjects (group 2) had bronchial hyperresponsiveness (BHR) (PD20 ≤ 2,000 μg). After withdrawal of ICS treatment, subjects were followed up for 3 weeks and were asked to record their asthma symptoms (cough, dyspnea, and wheezing) and their β2-agonist use. At recruitment and at the end of follow-up, subjects underwent spirometry and a methacholine challenge test. Frequency of asthma exacerbation was similar in subjects with normal bronchial responsiveness (NBR) and in subjects with BHR (50% vs 60%), but subjects with NBR tended to remain asymptomatic for longer than those with BHR (mean±SD, 10.7±4.4 days vs 5.5±3.8 days) (p=0.08). None of the subjects reported any condition that could have triggered exacerbation. Asthma exacerbation was associated with a significant decrease in FEV1 (–105 ±107 mL; p<0.05) and in PD20 (–1,332±1,020 μg; p<0.001).

Conclusions

Our study shows that the likelihood of asthma exacerbation is not reduced if ICS treatment is withdrawn when the subjects have NBR, but the exacerbation could be delayed. Further studies in larger populations of asthmatics are needed to confirm these findings.

Section snippets

Subjects

Our study included 18 subjects with mild persistent asthma1 (11 men), attending the outpatient clinic at the Occupational Medicine and Toxicology Section, University of Perugia, Perugia, Italy. At diagnosis, all subjects had BHR or reversible airflow obstruction, and persistent mild symptoms of asthma. Nine subjects were atopic. Atopy was defined as the presence of a positive skin test reaction to one or more common aeroallergens.6 Each subject was in stable condition and had not received oral

RESULTS

Four subjects with NBR and six subjects with BHR experienced asthma exacerbation after ICS treatment withdrawal, a frequency similar in the two groups (60.0% vs 50.0%) (p=0.914) (Table 2). During the study, none of the subjects were exposed to any allergen to which they were sensitive or had symptoms of respiratory tract infections.

Subjects with NBR tended to remain asymptomatic after ICS treatment withdrawal for a longer period than those with BHR (10.7±4.4 days vs 5.5±3.8 days) (mean±SD)

DISCUSSION

Our study shows that the normalization of BHR is not a reliable index assessing the opportunity of ICS treatment withdrawal in asthmatic subjects.

The increasing use of ICS in asthma treatment (with its risk of adverse effects and its cost) has indicated that an objective parameter of asthma severity is needed for correct management of therapy. In particular, the opportunity of ICS treatment withdrawal needs to be assessed objectively. Therefore, since it is an important determinant of the

ACKNOWLEDGMENT

The authors thank Dr. G. A. Boyd for her help in reviewing this article and Stefania Rometta for her secretarial assistance.

REFERENCES (10)

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Supported by a grant from MURST (40%).

Presented in part at the European Respiratory Society Annual Congress, Nice, France, October 1994.

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