[Garrett J, Williams S, Wong C, Holdaway D. Treatment of acute asthmatic exacerbations with an increased  dose of inhaled steroid. Arch Dis Child 1998; 79: 12-17].

The 1993 British Thoracic Society Asthma Management Guidelines suggested that the dose of inhaled steroids may be increased at the onset of common cold or worsening of asthma though there is no sound scientific evidence to substantiate the advantages of this therapy(1). Later guidelines in 1995, continued to state the lack of trials showing any substantial benefit from high dose of in­haled steroids in acute asthma(2). This study investigated the efficacy of an increased dose of inhaled steroid in the self management of exacerbations of asthma.

This randomized double blind placebo controlled trial was conducted on twenty eight children aged 6-14 years with asthma of mild to moderate severity; who were on inhaled steroid prophylaxis not exceeding 800 μg/- day. Children with concurrent illness, those on oral steroids, sodium cromoglycate, long acting β₂ agonists or those with change in the dose of inhaled steroids in the past two months were excluded. Eighteen pairs of exacerbations were available for analysis, during which subjects took an increased dose of in­haled steroids. There was no significant difference between increasing inhaled steroids or placebo on morning or evening peak expiratory flow rates (PEFRs), diurnal peak flow variability, or symptom scores in the two weeks following an asthma exacerbation. Difference (95% confidence intervals) in baseline PEFR on days 1-3 were 3.4% (-3.5% to 10.4%) and -0.9% (-4.7% to 2.9%) for inhaled steroid and placebo, respectively.

Spirometric function and the parents opinion of the effectiveness of asthma medications at each exacerbation were also not significantly different between inhaled steroid or placebo. This study suggests that increasing the dose of inhaled steroids at the onset of an exacerba­tion of asthma is ineffective and should not be included in asthma self management plans.

Comments

Steroids both inhaled and systemic have a definite role in the management of acute and chronic asthma, although no trials have specifically investigated the use of an increased dose of inhaled steroids for treating a deterioration of asthma. A study on 24 preschool children with acute asthma receiving 225 mg of beclomethasone dipropionate each day for five days resulted in decreased severity of asthma but duration of symptoms remained unchanged(3). Majority of children were not receiving any therapy as maintenance medication. In another study which examined the role of inhaled budesonide ( 800 μg twice a day) to prevent virus induced wheeze, it was shown that this therapy reduced symptoms but dura­tion of symptoms was not decreased(4).

This was further corroborated from a study in which reducing doses of inhaled budesonide continued to ameliorate asthma symptoms during an acute attack(5). But none of these trials investigated the role of higher dose of steroids in acute asthma. Though such an approach is commonly used by general practitioners in the self management of asthma(6) there is still no sound scientific evidence to support the same.

The current study showed that higher doses of inhaled steroids were not effective in the management of acute asthma. This study had certain limitations. The numbers employed were too small, and many of the differ­ences between steroid and placebo treatment were small and did not reach statistical significant. Further only children with mild to moderate asthma were included. It is plausible that higher doses of inhaled steroids would be advantages in children with severe acute asthma. The effects of higher dose of inhaled steroids may also be determined by the nature of trigger causing asthma exacerbation. Employing large number of children with varied etiology of asthma exacerbation may provide further information on the exact role of higher dose of inhaled steroids in acute asthma. Also in this study, a higher dose of inhaled steroids was used only for brief periods. Whether prolonging the duration of therapy would be beneficial remains to be determined.

Thus this study suggests that administration of increased dose of inhaled steroids does not improve the clinical course of acute asthma and that this increase should not be included in an asthma self management plan.

                                   K. Rajeshwari,
              Department of Pediatrics,
Maulana Azad Medical College,
 New Delhi 110002,
India.