Clinical Question

Which strategy is superior in managing inhaled steroid therapy in adults with asthma: symptom-based, biomarker-based, or physician-based?

Bottom Line

In this study, symptom-based dose adjustment of inhaled steroids (instructing patients to take two puffs of inhaled steroids every time they took two puffs of albuterol for relief of symptoms) resulted in similar treatment outcomes compared with a dosing strategy based on physician assessment using widely distributed and highly touted standard national guidelines, and compared with a biomarker-based strategy using exhaled nitric oxide. In addition, the symptom-based therapy resulted in only approximately one-half the amount of total monthly steroid use. It will likely require more confirming clinical trials before standard treatment consists of allowing patients to adjust inhaled corticosteroid use to match their need for rescue albuterol—even though this strategy is simple and doesn't require a highly trained clinician's input! (Level of Evidence = 1b–)

Reference

CalhounWJAmeredesBTKingTSet alAsthma Clinical Research Network of the National Heart, Lung, and Blood Institute. Comparison of physician-, biomarker-, and symptom-based strategies for adjustment of inhaled corticosteroid therapy in adults with asthma: the BASALT randomized controlled trial. JAMA.2012; 308( 10): 987– 997.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Uncertain

Setting: Outpatient (any)

Synopsis

The optimal strategy for adjusting inhaled steroid therapy in adults with asthma is uncertain. These investigators identified 342 consenting adults with well-controlled or partially controlled asthma with or without low-dose inhaled steroids. Patients randomly received assignment (uncertain allocation concealment) to one of three treatment-management groups: (1) physician assessment based on widely distributed guidelines from the National Heart, Lung, and Blood Institute National Asthma Expert Panel; (2) measurement of exhaled nitric oxide; or (3) symptom-based, in which inhaled steroid dose is matched on a puff-per-puff basis with as-needed albuterol use. Dose adjustments occurred at clinic visits every six weeks in the first two strategies and as needed by patients in the third strategy. Primary outcomes included unscheduled medical contact for increased asthma symptoms resulting in the use of oral steroids, increased inhaled steroids, or additional medications for asthma. Patients and their physicians remained aware of treatment group assignment. Complete follow-up occurred for 80 to 89 percent of participants at nine months. Using intention-to-treat analysis, time to treatment failure and treatment failure rates did not significantly differ among the three treatment strategies. Mean monthly steroid use was significantly higher in the physician-based and biomarker-based groups than in the symptom-based group (mean beclomethasone [Beconase AQ] use = 1,610 versus 830 mcg). The study was 87 percent powered to detect a predetermined clinically significant difference in treatment failure rate among the three strategies.