A comparison of inhaled salbutamol with a combination of salbutamol and beclomethasone dipropionate in moderately severe asthma

Fifteen adults with moderately severe asthma underwent two sequential treatments, first with inhaled salbutamol, 200 micrograms q.i.d. for 2 weeks followed by a combination of salbutamol 200 micrograms and beclomethasone dipropionate (BDP) 100 micrograms q.i.d. for the next 2 weeks. The response was evaluated by symptoms and additional drugs scores during the two treatments and spirometry before and after each treatment. The second phase of treatment resulted in a greater symptomatic improvement and a reduced need for additional drugs. A clinically significant improvement was observed in lung function after the combination treatment. However, as the comparison was limited to only 2 weeks, this duration of treatment was not adequate to correct the spirometric abnormalities. It was concluded that a combination of salbutamol and BDP was superior to salbutamol alone. Treatment with only bronchodilators results in a poor control of asthma and therefore, these should always be combined with inhaled steroids.

Effects of short-term and long-term treatment with inhaled corticosteroids on bone metabolism in patients with airways obstruction. Dutch CNSLD Study Group

BACKGROUND

Recent reports have suggested short-term changes in serum parameters of bone metabolism with inhaled corticosteroids. The relevance of these findings to the balance between bone formation and resorption during years of corticosteroid treatment remains uncertain.

METHODS

Two novel markers of bone turnover were first compared with conventional markers in a pilot study and subsequently measured in a long-term double blind study of inhaled corticosteroids. In study I 15 patients were newly started on at least 800 micrograms inhaled corticosteroids daily. At entry and after four weeks serum levels of alkaline phosphatase, osteocalcin, and PICP (procollagen type I carboxy terminal propeptide; a procollagen splice product) were measured as markers of bone formation, as well as the urinary hydroxyproline/creatinine ratio and serum levels of ICTP (type I collagen carboxy terminal telopeptide; a collagen degradation product) as markers of bone resorption. In study II 70 patients with airways obstruction received 800 micrograms beclomethasone daily in addition to terbutaline and 85 received bronchodilators only in a double blind fashion. Serum levels of PICP and ICTP were measured before and after 2.5 years of treatment.

RESULTS

In study I a decrease in osteocalcin levels was accompanied by an increase in levels of PICP and a small and non-significant rise in alkaline phosphatase. There were no changes in hydroxyproline or ICTP. In study II no differences were found in serum levels of PICP between the treatment groups; an increase in serum ICTP was found in the group treated without inhaled corticosteroids compared with the group treated with inhaled corticosteroids.

CONCLUSIONS

No detrimental long-term effect of inhaled corticosteroids was found with three conventional and two novel parameters of bone metabolism. The results indicate that long-term changes in bone turnover during treatment with inhaled corticosteroids should not be deduced from short-term studies with single serum parameters of bone metabolism, but well designed long-term studies of, for example, bone densitometry should be awaited before quoting detrimental effects of inhaled corticosteroids on bone metabolism.

Comparison of two beclomethasone dipropionate inhalation aerosol spacer combinations in the treatment of asthma

Fifty-five asthmatics, previously treated with inhaled steroids (mean age 48 years, range 16-68 years, mean duration of the disease 10 years, range 1-35 years) participated in this multicentric 2-phase trial. The patients were in good clinical condition (basal FEV1 3.02 litres (1.38-6.29), 90% (48-131%) of predicted values; mean (range)). In the first phase (randomized, double-blind crossover study) 2 beclomethasone dipropionate (BDP) inhalation aerosol preparations (MDI) were administered through collapsible spacer. In the second phase (open, randomized, parallel group comparison), 1 of the preparations was administered via collapsible and the other via traditional large volume spacer. The total daily dose of inhaled beclomethasone was 1,000 micrograms. The evaluation of efficacy was based on peak flow monitoring (PEFR) carried out at home twice daily and on FEV1 measured in spirometry at control visits after the run-in period and after each 4-weeks treatment period. Side-effects and asthma symptoms were recorded on patient diaries. The patients were asked to evaluate the treatment efficacy and the use and handling of the MDI-spacer combinations with Visual Analog Scale (VAS) at the end of each treatment period. No statistically significant differences were found in PEFR or FEV1 between the treatments during whole study. The asthma symptom scores were low as well as the use of concomitant inhaled sympathomimetics which indicates good and equal efficacy of the preparations. The MDI-spacer combinations were equally well tolerated. According to the VAS scores, the collapsible spacer was easier to use and statistically significantly easier to handle than traditional large volume spacer.

Comparative safety and efficacy of single or twice daily administration of inhaled beclomethasone in moderate asthma

OBJECTIVES

In the treatment of stable mild to moderate asthma, twice-daily administration of inhaled steroids may allow adequate control of the asthma; however, comparisons of the efficacy of once- or twice-daily administration brought contradictory results. This study is a randomized, double-blind crossover trial, set to determine if inhaled beclomethasone dipropionate given once daily in the late afternoon or at bedtime can be as effective as a twice-daily regimen in the treatment of moderate asthma.

DESIGN

Subjects were randomly assigned to 3 different dosing regimens of inhaled beclomethasone: (1) regimen A, a twice-daily dose of 500 micrograms in the morning and at bedtime; (2) regimen B, a single dose of 1,000 micrograms in the late afternoon; and (3) regimen C, a single dose of 1,000 micrograms at bedtime.

PATIENTS AND PARTICIPANTS

Enrolled in the study were 42 subjects who required 500 micrograms of inhaled beclomethasone dipropionate twice daily to control symptoms of asthma and to minimize use of beta 2-adrenergic agonists, according to criteria suggested in a recent international consensus on asthma therapy. Prior to receiving therapy with inhaled steroids, all of these patients either had chronic symptoms of asthma that required administration of a short-acting beta 2-agonist at least twice per day, or had nocturnal asthma symptoms at least once per week.

THERAPY

After a 2-week baseline evaluation, each subject was given the 3 treatment regimens in randomized order, each for a period of 4 weeks. Subjects were asked to record daily symptoms of asthma and peak expiratory flows in the morning and evening. At the end of each treatment period, spirometric data and airway responsiveness to methacholine were measured.

MEASUREMENTS AND RESULTS

Thirty-seven subjects completed the study. No significant difference was found among the 3 treatment regimens for asthma symptoms, FEV1, the provocative concentration of methacholine causing a 20 percent decrease in the FEV1 (PC20) (geometric means, 1.41, 1.09, and 1.09 mg/ml), and mean morning and evening peak expiratory flow rates (PEFR). The plasma cortisol level and the adrenocorticotropic hormone (ACTH) response were not significantly different among treatments, nor were side effects, which were minimal.

CONCLUSION

In moderate asthma controlled with a twice-daily dose of inhaled beclomethasone, a single total daily dose administered in the late afternoon or in the evening provides as good control of asthma for 2 months.

Anaesthetic management of an asthmatic child for appendicectomy

A 13-yr-old boy was scheduled for emergency appendicectomy because of abdominal pain. His preoperative medical history was complicated by a recent hospital admission for management of asthma. He had presented to hospital seven days earlier because of dyspnoea, tachypnoea and oxygen desaturation to 77% on room air. Following admission, he required intensive nonventilatory management of his asthma, including intravenous salbutamol, methylprednisolone, and aminophylline, as well as use of an ipratroprium bromide inhaler and 100% oxygen by mask. He was discharged to the ward, and continued on prednisone (delta-cortisone), beclomethasone inhaler, ipratroprium inhaler, and salbutamol inhaler. During his ICU stay, he complained of nonspecific abdominal pain, interpreted as gastro-oesophageal reflux. After four days, he was discharged to the ward. On his sixth hospital day, he began to experience right-sided lower abdominal pain and right shoulder pain. A surgeon was consulted, and the patient was found to have a very tender right lower quadrant with guarding and rebound pain. He was therefore scheduled for appendicectomy; antibiotic therapy with ampicillin, gentamicin, and metronidazole was initiated.

Cushing's syndrome from an inhaled glucocorticoid

OBJECTIVE

To report a case of significant systemic side effects from an inhaled glucocorticoid at a reported dose in the upper recommended therapeutic range.

CLINICAL FEATURES

A 25-year-old white man with asthma treated with inhaled glucocorticoid (beclomethasone 1500 micrograms daily), and primary testicular failure with inadequate androgen replacement, was referred with back pain. He was found to have osteoporosis, clinical features of Cushing's syndrome and complete suppression of endogenous adrenocorticotrophic hormone adrenal function.

INTERVENTION AND OUTCOME

He was recommended to receive adequate androgen replacement and to use a spacer device with the inhaled beclomethasone, or to change to budesonide via a Turbuhaler (AB Astra, Sweden).

CONCLUSIONS

Inhaled glucocorticoids should not be regarded as entirely safe, as serious systemic side effects may occur at doses at the upper level of the recommended therapeutic range.

A comparison of fluticasone propionate 200 micrograms/day with beclomethasone dipropionate 400 micrograms/day in adult asthma

A total of 261 patients with symptomatic, mild to moderate asthma were randomized to treatment in this 4-week, double-blind, parallel-group comparison of fluticasone propionate 200 micrograms/d with beclomethasone dipropionate 400 micrograms/d. Improvements from both treatments were seen in diary card data. Morning peak expiratory flow rate (PEFR) improved from 375 to 390 and 371 to 382 l/min with fluticasone propionate and beclomethasone dipropionate, respectively. Symptom scores, percentage of symptom-free days and nights, and use of rescue beta 2-agonist medication also improved, as did clinical lung function. With the exception of percentage of rescue-free days, which was greater for beclomethasone dipropionate, none of the differences between the groups were statistically significant. There was a significant difference between treatments in the number of rescue-free days over days 1-28; however, there was no difference between treatments in the number of rescue-free days over days 1-14, nor was there any difference in the number of inhalations of rescue medication used throughout the study. Very few adverse effects were reported. Although all mean plasma cortisol values were within the normal range, they were significantly different between treatments, rising from 402 to 429 nmol/l with fluticasone propionate, and falling from 435 to 394 nmol/l with beclomethasone dipropionate (P = 0.006). Mean stimulated cortisol levels 30 min after tetracosactin injection were also significantly greater with fluticasone propionate (P = 0.024). In conclusion, fluticasone propionate 200 micrograms/d is as effective as beclomethasone dipropionate 400 micrograms/d with less effect on plasma cortisol levels.

Effect of beclomethasone dipropionate on bone mineral content assessed by X-ray densitometry in asthmatic children: a longitudinal evaluation

There is little information on bone turnover in asthmatic children taking long-term treatment with inhaled steroids (ICS). The aim of this longitudinal study was to determine the effects of inhaled beclomethasone dipropionate (BDP) on bone mineral density (BMD), in asthmatic children treated over a period of six months. BMD and growth were studied in two age- and sex-matched groups of asthmatic children. These comprised: 14 asthmatic children (Group 1) who had taken BDP in a dosage of 300-400 micrograms daily through a 145 ml spacer device for at least 6 months (mean age 9.1 yrs); and a control group of 16 age- and sex-matched asthmatic patients (Group 2) not treated with ICS (mean age 9.5 yrs). Mean duration of asthma was 5.7 yrs in Group 1 and 5.5 yrs in Group 2. Vertebral BMD (L2-L4) was measured by dual energy X-ray absorptiometry (DEXA) at the beginning (baseline) of the study and 6 months later. There were no significant differences in the baseline bone mass (mean +/- SEM) between the two groups (0.63 +/- 0.03 and 0.64 +/- 0.02 g.cm-2 in Group 1 and 2, respectively). During the observation period, bone density increased, by 4% (95% confidence interval (95% CI) 2-6) in the control group and by 2.3% (95% CI 0.4-4.2) in the group under BDP treatment, showing no significant influence of the treatment. No difference was found in height velocity evaluated before starting BDP and after 6 months of therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Airway inflammation in nonasthmatic subjects with chronic cough

The physiopathology of chronic cough remains obscure. We evaluated the possibility that chronic cough in nonasthmatic subjects is associated with airway inflammation, and if this is so, what the relationship between this inflammation and the possible etiology of cough might be, as well as its response to inhaled steroids. Nineteen nonsmoking, nonasthmatic subjects referred for a persistent cough (mean: 3.8 yr) were evaluated and compared with 10 normal subjects. The evaluation included a respiratory questionnaire, a physical examination, allergy skin-prick tests, chest and sinus radiographs, esophageal pH monitoring, measurements of expiratory flows, methacholine and citric acid challenges, and flexible bronchoscopy for bronchoalveolar lavage (BAL) and bronchial biopsies. Fourteen subjects further accepted participation in a randomized, double-blind crossover trial of inhaled beclomethasone (500 micrograms four times daily) and a placebo for 1 mo each. Four groups of subjects were identified according to the presence of postnasal discharge (n = 4), gastroesophageal reflux (n = 6), both conditions (n = 5), or neither (n = 4). Subjects with chronic cough had an increased number of inflammatory cells in their bronchoalveolar lavage fluid (BALF), but there was no significant difference between the four subgroups of coughers. As compared with control subjects, the bronchial biopsies of subjects with chronic cough showed increased epithelial desquamation (p = 0.004) and inflammatory cells (p = 0.005), particularly mononuclear cells (p < 0.01), in addition to submucosal fibrosis, squamous-cell metaplasia, and loss of cilia. These findings were not significantly different between the different etiologic groups. In subjects with chronic cough, basement-membrane thickness was normal and not different from that of control subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Fluticasone propionate: an effective alternative treatment for seasonal allergic rhinitis in adults and adolescents

BACKGROUND

Topical corticosteroids are widely regarded as the reference standard in allergic rhinitis therapy because they are well tolerated and effective against all rhinitis symptoms. We evaluated the efficacy, onset of action, and safety of two dosing regimens of the new corticosteroid fluticasone propionate compared with that of beclomethasone dipropionate in patients with moderate to severe seasonal allergic rhinitis.

METHODS

In this double-blind, randomized multicenter trial, 110 adolescents and 128 adults were treated for 4 weeks with one of the following regimens: fluticasone aqueous nasal spray 100 micrograms twice daily or 200 micrograms once daily, beclomethasone aqueous nasal spray 168 micrograms twice daily, or placebo.

RESULTS

Patient-rated scores for nasal obstruction, rhinorrhea, and combined nasal symptoms indicated that the two fluticasone regimens were equally effective and that both were superior to beclomethasone during most of the study (P < or = .05) and to placebo throughout the study (P < or = .01). Both fluticasone regimens also demonstrated significant clinical efficacy by 24 hours after the first dose. Clinician-rated mean total nasal symptoms scores for all three active treatments were superior to placebo at most time points but were not significantly different from each other. All treatments were well tolerated, with similar incidence and type of adverse events in all treatment groups and no apparent effects on hypothalamic-pituitary-adrenal (HPA) axis function.

CONCLUSIONS

Fluticasone aqueous nasal spray was effective in relieving nasal symptoms in adolescents and adults with seasonal allergic rhinitis. Fluticasone administered once or twice daily was superior to beclomethasone administered twice daily in relieving nasal obstruction and rhinorrhea and in reducing nasal symptoms more quickly.

Inhaled beclomethasone dipropionate downregulates airway lymphocyte activation in atopic asthma

It is widely known that inhaled corticosteroids are highly efficacious in the prophylactic treatment of asthma, but the mechanism of this action is not known. In this study we have investigated the effect of 6 wk of therapy with inhaled beclomethasone dipropionate (BDP; daily dose 2,000 micrograms for 2 wk and 1,000 micrograms for 4 wk) in a group of symptomatic individuals with asthma on clinical and physiologic indices of disease activity and on T cell numbers and state of activation in peripheral blood and bronchoalveolar lavage (BAL). This course of treatment had a marked effect of improving all indices of disease activity including symptom scores, morning peak expiratory flow (PEF), variation in PEF, and methacholine PC20 (from a geometric mean of 0.62 to 4.6 mg/ml) but did not alter the total numbers of T cells, identified by the CD3 receptor, or the CD4+ and CD8+ subsets when analyzed in peripheral blood or BAL using flow cytometry. However, BDP treatment had a marked effect in reducing the expression of the activation markers CD25 and HLA-DR (p < 0.02) in T cells recovered by BAL in which these markers were upregulated. A small but significant (p < 0.02) downregulation of HLA-DR expression was also observed on peripheral blood T cells. These data add to the view that T cells are upregulated in the airways of individuals with asthma and are susceptible to inhibition by topical corticosteroids.

Pituitary-adrenal function in asthmatic patients treated with high dose of beclomethasone

Ten asthmatic patients receiving long term treatment with high dose of inhaled beclomethasone dipropionate (BDP) (750 to 2,250 micrograms/die, average 1,400 +/- 474 micrograms) underwent evaluation of hypothalamic-pituitary-adrenal (HPA) axis under basal conditions (serum cortisol and ACTH levels at 8.00 AM and 8.00 PM, 24-hours free urinary cortisol) and by means of pharmacological tests (short tetracosactide and Corticotrophin Releasing Factor Tests). Basal ACTH serum levels at 8.00 PM were lower than the normal values in all patients: three patients had reduced 24-hr free urinary cortisol and six subjects showed lower cortisol serum levels at 8.00 PM. A normal response to the short tetracosactide test was observed in all patients, whilst Corticotrophin Releasing Factor (CRF) induced an increase in ACTH and cortisol levels (expressed as delta AUC) that was significantly lower in the BPD treated patients compared with a control group of five healthy subjects (p < 0.05). Thus BPD, in high doses, may cause a partial inhibition of HPA axis. Our results show that determination of basal ACTH level and CRF test are more sensitive than serum cortisol levels and short tetracosactide test to evaluate a suppression of HPA axis in patients receiving long term inhaled high doses of BDP.

Inhaled steroids and severe viral infections

In summary, the blanket inclusion of inhaled corticosteroids in the recent FDA label warning of an association between severe varicella infection and corticosteroid therapy without reference to dosage, and proof of immunosuppression and subsequent increased risk, dose not appear warranted. To date, no link has been established between inhaled steroids and pulmonary or systemic infections. Certainly, with the recent trend of use of higher doses of inhaled corticosteroids, a potential association is possible, but so far, this is only theoretical. Since inhaled corticosteroids have become the recommended drug of choice for many patients with asthma of varying disease severity, according to new recommendations from the National Heart Lung and Blood Institute (38), it is imperative that a sound basis of proof be provided to support this labeling change. It must be realized that this new warning may lead to adverse consequences resulting from the withholding by the patient or physician of a valuable mode of therapy for fear of adverse effects to the patient. Avoidance of inhaled steroid usage, in turn, could result in overuse of other medication that has more definite and frequent deleterious effects than the theoretical risks associated with inhaled steroids. Given the above information and arguments, a number of constructive recommendations about how to proceed at this time can be proposed.

Effect of beclomethasone dipropionate nasal aerosol on serum markers of bone metabolism in children with seasonal allergic rhinitis

Thirty-nine children with grass pollen hay fever were randomly treated with nasal inhaled beclomethasone dipropionate (BDP) 200 or 400 microg/day or sodium cromoglycate (SCG) 30 mg/day for 2 months during the pollen season. Serum osteocalcin (OC), parathyroid hormone (PTH), total alkaline phosphatase (AP), bone alkaline phosphatase (BAP) and type I collagen telopeptide (ICTP) were measured immediately before, 1 and 2 months after treatment and 1 week after stopping the therapy. No significant changes in OC, PTH, AP, BAP and ICTP serum level occurred within each group. Minor and probably clinically insignificant between group differences were occasionally found. Our study shows that BDP nasal spray has no significant effect on common markers of bone metabolism.

A multicentre study to assess long-term use of fluticasone propionate aqueous nasal spray in comparison with beclomethasone dipropionate aqueous nasal spray in the treatment of perennial rhinitis

Two hundred and fifty-one patients, aged 16 years and over, with perennial rhinitis were recruited to this multicentre, randomized, double-blind, parallel group study. One hundred and fifty-nine patients received fluticasone propionate (200 micrograms) aqueous nasal spray (FPANS) twice daily, and 83 patients received beclomethasone dipropionate (200 micrograms) aqueous nasal spray (BDPANS) twice daily; treatment randomization being 2:1, respectively, in order to increase the number of patients in the FPANS group as FPANS was the drug under study. After 1 year of treatment, nasal blockage (p = 0.002), nasal discharge (p = 0.002) and eye watering/irritation (p = 0.048) were significantly improved in patients treated with FPANS twice daily, compared to patients treated with BDPANS twice daily. The symptom grades for nasal itching (p = 0.052) were improved in the FPANS group, but just failed to attain statistical significance at the 5% level. The symptom grades for sneezing tended to be better for the FPANS group, but the difference was not statistically significant. Assessment of changes in the findings during nasal examination (rhinoscopy) and in haematological, biochemical and urinary parameters, and measurements of plasma cortisol levels during the one year of treatment with the study drugs, showed that there were no clinically significant differences between the two treatment groups and that the study drugs were equally well tolerated. This study indicates that long-term use of FPANS provides better relief than BDPANS for most of the symptoms of perennial rhinitis.

The effect of intranasal azelastine and beclomethasone on the symptoms and signs of nasal allergy in patients with perennial allergic rhinitis

A double-blind, randomized, parallel-group, placebo-controlled study involving 130 patients was conducted at 9 centres in the U.K. to assess the effect of 6 weeks of treatment with azelastine nasal spray (azelastine) and beclomethasone dipropionate nasal spray (BDP) on the symptoms of perennial rhinitis. Efficacy was assessed by patients recording daily the severity of the symptoms of rhinitis on 10-cm visual analogue scales. Analysis of this diary data showed significant reductions in sneezing, blocked nose, running nose, and itching nose during azelastine treatment. Patients on BDP recorded a consistent reduction in rhinitis symptoms, but these reductions were significant only for sneezing on treatment day 7. When rhinitis symptoms were assessed by clinical investigators on a 4-point scale, the scores obtained following treatment with the 2 study medications showed little change from baseline or "active" treatment scores. There was no evidence of a consistent change in nasal airway resistance, measured using anterior rhinomanometry, following treatment with either BDP or azelastine. Azelastine nasal spray and BDP nasal spray were well tolerated by the patients and the relative incidence of adverse events was similar in the azelastine and placebo/azelastine treatment groups, except that taste perversion occurred more frequently during azelastine treatment than during placebo/azelastine treatment. There was no evidence of an increased incidence of somnolence or fatigue in patients who received azelastine nasal spray. Overall, the results of this study indicate that azelastine administered twice daily as an intranasal spray is a safe and efficacious treatment for the symptoms of rhinitis in patients suffering from mild to moderate perennial rhinitis.

Intranasal steroids inhibit seasonal increases in ragweed-specific immunoglobulin E antibodies

We performed two seasonal studies to evaluate the effect of continuous treatment with intranasal steroids, beginning approximately 1 week before the appearance of ragweed pollen, on the level of ragweed-specific IgE antibodies in serum. In both studies the control groups showed the anticipated rise in ragweed-specific IgE antibodies after the ragweed season. In the first study, employing aqueous beclomethasone dipropionate (168 micrograms twice daily), no rise occurred in serum ragweed IgE after seasonal exposure and the level actually decreased in eight of 12 treated subjects. In the second study, with triamcinolone acetonide (220 micrograms twice daily), the expected rise in ragweed IgE antibody was also reduced, although less dramatically, probably as a result of the lower potency of the dose delivered. Our studies not only support the benefits of intranasal steroids in the treatment of seasonal allergic rhinitis but also suggest that specific IgE production may be down-regulated by their continuous use, which may alter the subsequent clinical course of the disease.

Current concepts in asthma management

This short paper investigates the effects of prophylaxis on re-admission rates at the Royal Alexandra Hospital for Children, Camperdown, New South Wales.

Evolution of asthma treatments

The treatment of asthma has undergone dramatic changes in the past two decades. These changes stem from the marked increase in our understanding of the pathophysiology of asthma as well as from the availability of potent and effective therapeutic agents. This review discusses the current treatment of asthma considered from a pathophysiologic perspective, focusing on the roles of specific and symptomatic approaches. Specific therapies are aimed at the underlying processes causing asthma, with the goal of reducing symptoms and the need for concomitant medication. Choices include allergen avoidance, immunotherapy, inhaled cromolyn or nedocromil, and inhaled or oral corticosteroids. Symptomatic therapies that control the symptoms of asthma without affecting the underlying causes are used alone or to provide coverage in the period before specific therapies take effect. Here the options are beta agonists, theophylline, and anticholinergic agents. This article weighs the advantages and disadvantages of each of the principal therapies and discusses today's major controversies, including the link between beta-agonist use and asthmatic deaths, theophylline toxicity, and the efficacy of immunotherapy.