Beclomethasone dipropionate: a new steroid aerosol for the treatment of allergic asthma

Efficacy of inhaled fluticasone propionate in asthma results from topical and not from systemic activity

The objective of this study was to determine whether the therapeutic benefits of inhaled fluticasone propionate are mediated through topical or systemic effects. Two hundred seventy-four patients with asthma receiving beclomethasone dipropionate or triamcinolone acetonide during a 2-wk, single-blind, run-in period were randomized to inhaled fluticasone propionate powder 100 or 500 micrograms twice daily, oral fluticasone propionate 20 mg once daily, or placebo during a 6-wk treatment period. Patients receiving inhaled fluticasone propionate had a significantly greater probability of remaining in the study over time compared with patients receiving oral fluticasone propionate or placebo (p = 0.001). FEV1 and PEF rates at end point were significantly higher with inhaled fluticasone propionate treatment regimens than with oral fluticasone propionate (with the exception of PEF rates for inhaled fluticasone propionate 100 micrograms) or placebo treatments (p < or = 0.004). Systemic exposure to fluticasone propionate as assessed by trough plasma concentrations and/or 12-hr plasma concentration area under the curve analyses (AUC12) was higher with the oral fluticasone propionate than with the two inhaled fluticasone propionate treatment groups. The results of this study suggest that the therapeutic benefits of inhaled fluticasone propionate are mediated through topical effects in the lungs and not through systemic effects.

Hospitalization of adults for asthma and inhaled corticosteroid use in an island population

Inhaled corticosteroids have been shown to reduce morbidity and the need for hospitalization from asthma. Despite improvements in the therapy of asthma, epidemiologic data from several countries has shown that the hospital admission rates for asthma among adults at a population level are on the increase. The prevalence rate of hospital admission for asthma among Maltese adults aged 15-59 years was determined retrospectively from 1989 to 1993. Concurrent yearly total dispensal of inhaled corticosteroids for the whole population was also calculated. This study was undertaken amongst a well-defined island population served by a single medical facility offering emergency services, and a possible association between these two trends was investigated by means of logistic regression. The age-specific hospital admission rates for asthma decreased from 96.2 (95% CI: 109.7, 82.7) per 100,000 in 1989 to 38.1 (95% CI: 46.4, 29.8) per 100,000 in 1993. The prevalence rates of admission from asthma decreased from 67.6 (95% CI: 78.9, 56.3) per 100,000 in 1989 to 30.6 (95% CI: 38.0, 23.2) per 100,000 in 1993. The dispensal of inhaled beclomethasone dipropionate (BDP) increased from 0.99 defined daily dose (DDD) per 1000 population in 1989 to 3.28 DDD per 1000 in 1993. Logistic regression showed that increasing dispensal of inhaled BDP by 1 DDD per 1000 decreased the odds of an admission from asthma to 0.71 (95% CI: 0.65, 0.78) times their previous value. Similarly, the odds of an individual being hospitalized because of asthma decreased to 0.75 (95% CI: 0.67, 0.83) times their previous value. This study concludes that there was a progressive decrease in hospital admission rates for asthma in adults, and this trend correlates well with increasing use of inhaled corticosteroids at a community level. This must, however, be interpreted with care in light of the fact that increase in utilization of anti-inflammatory therapy probably also reflected improved general and widespread care for asthma.

Steroid therapy in obstructive airway diseases

Asthma and chronic obstructive pulmonary disease (COPD) are two common illnesses that cause significant morbidity and mortality. Steroids are widely used in both conditions. They act through steroid or glucocorticoid receptors (GR) causing up or down regulation of protein synthesis resulting in an increase in lipocortin 1 and beta 2 adrenergic receptors, and decreased levels and activities of cytokines or cytokine receptors, which reduces the inflammatory process in the airways and decreases bronchial hyperreactivity. Consequently symptoms of airway obstruction are alleviated and lung function is improved. In asthma, steroids have been convincingly shown to be effective in the treatment of both acute exacerbations and chronic condition. In COPD, however, only a subset of patients seem to respond favourably to steroid therapy. Therapeutic trials are therefore recommended before committing to a long-term treatment in order to determine this subset of patients, as no markers of steroid responsiveness can be identified. The inhaled steroids currently available have a good safety profile with significant side effects occurring only occasionally. Such side effects are usually confined to the oropharynx, causing local irritation, candidiasis and dysphonia, which can be easily overcome. Biochemical abnormalities involving bone, adrenal, carbohydrate and lipid profiles have been noted with high doses of inhaled steroids; however, these have no significant clinical effects.

Effect of nebulized lidocaine on severe glucocorticoid-dependent asthma

OBJECTIVE

To determine whether nebulized lidocaine is a useful therapy in patients with severe glucocorticoid-dependent asthma.

DESIGN

We prospectively conducted an open study of the effects of administration of nebulized lidocaine four times daily in 20 patients with asthma who had side effects of exogenous hypercortisolism.

MATERIAL AND METHODS

The 18 women and 2 men, who were 19 to 71 years of age, all had severe asthma that necessitated both topical and systemic administration of glucocorticoids to control symptoms of airflow obstruction. Treatment consisted of nebulized lidocaine, 40 to 160 mg four times daily. Initially, all topical and systemic glucocorticoid regimens were maintained; if peak flow rates remained stable and symptoms of asthma were well controlled, orally administered glucocorticoid regimens were slowly reduced.

RESULTS

Thirteen patients were able to discontinue oral use of glucocorticoids entirely, despite prolonged glucocorticoid dependence (mean 6.6 years and median 3 years for the 20 patients); 4 achieved reduction in their daily glucocorticoid requirement while maintaining control of symptoms of asthma (duration of glucocorticoid dependence for responders, mean 6.2 years and median 3.2 years). Three patients had no apparent response, as determined by their continued severe asthma symptoms and inability to reduce oral glucocorticoid requirements.

CONCLUSION

These results suggest that nebulized lidocaine is a useful therapy for chronic asthma, allowing reduction or elimination of oral glucocorticoid therapy.

The efficacy and tolerability of fluticasone propionate aqueous nasal spray in children with seasonal allergic rhinitis

Fluticasone propionate aqueous nasal spray (FPANS) contains fluticasone propionate, which is a new topically active glucocorticoid with approximately twice the potency of belcomethasone dipropionate. In this European multicentre study, 143 children with seasonal allergic rhinitis were recruited: 47 received FPANS 100 micrograms once a day (od), 46 received FPANS 200 micrograms od, and 50 patients received placebo od, for 4 weeks. Treatment efficacy was assessed using diary card nasal symptom scores for sneezing, rhinorrhoea, blockage and itching, and eye watering/irritation. Patients receiving FPANS 100 micrograms or FPANS 200 micrograms demonstrated statistically significant improvements in median nasal symptom scores in all the symptoms recorded, when compared with placebo. There were no statistically significant differences between the FPANS 100 micrograms and FPANS 200 micrograms groups in improvement in nasal symptom scores. There was no effect on eye watering/irritation symptoms which could be attributed to either FPANS 100 micrograms or FPANS 200 micrograms when compared with placebo. Use of rescue antihistamine medication was significantly reduced in the FPANS 100 micrograms group when compared with placebo. The adverse events profile was similar in all three treatment groups, and the events reported were generally mild and related to the patients' rhinitis.

Adverse effects of inhaled corticosteroids

Inhaled corticosteroids are considered by many to be the anti-inflammatory therapy of choice in adult asthma, given their remarkable efficacy and apparent safety. They are presently being prescribed to more patients, at larger doses, and for longer periods of time than ever before. Oropharyngeal candidiasis and dysphonia are the most commonly recognized adverse effects of therapy, but these topical phenomena cause no significant morbidity and are easily managed. By contrast, there is now increasing concern about the potential systemic effects of inhaled corticosteroids. These putative effects may include adrenal suppression, bone loss, skin thinning, increased cataract formation, decreased linear growth in children, metabolic changes, and behavioral abnormalities. Changes in adrenal function have been noted in patients using medications such as beclomethasone dipropionate and budesonide in doses exceeding 1,500 micrograms/day. The clinical relevance of these changes has yet to be clarified. Several short-term and cross-sectional studies have also revealed changes in biochemical markers of bone turnover and retrospective studies have found reduced bone density in asthmatics treated regularly with inhaled steroids. Long-term prospective studies assessing bone density changes remain to be done. Although much controversy exists, there is no unequivocal evidence that conventional doses of inhaled steroids significantly retard bone growth in children. Reports on skin changes, increased cataract formation, and behavioral changes are difficult to interpret because of several confounding factors. Although inhaled steroids should, at the present time, continue to be a recommended therapeutic option to all patients with symptomatic asthma, they should always be used in the lowest dosage compatible with disease control.

Effect of short-term treatment with fluticasone propionate nasal spray on the response to nasal allergen challenge

The aim of the study was to investigate the effect of short-term treatment with fluticasone propionate on the response to nasal allergen challenge in patients with allergic rhinitis. Responses to nasal allergen challenge were assessed subjectively by recording symptom scores on visual analogue scales, and objectively by measuring histamine, PGD2 and LTC4 in nasal lavage and by measuring nasal inspiratory peak flow following challenge. Nasal allergen challenge resulted in an increase in all symptom scores (P < 0.05); an increase in histamine and PGD2 (P < 0.05), and a decrease in nasal inspiratory peak flow at 1 h, 5 h and 7 h following challenge (P < 0.05). The allergen-induced changes in symptom scores, mediator levels and nasal inspiratory peak flow were attenuated by treatment with fluticasone propionate (P < 0.05 for all parameters measured). Post-challenge nasal obstruction was decreased by 45%; sneezing, itching and rhinorrhoea by 73, 78 and 80% respectively in the group as a whole comparing scores whilst on fluticasone propionate with those on no therapy. Fluticasone propionate, 200 micrograms twice daily for 2 weeks is effective in reducing significantly the early and late response to nasal allergen challenge.

Inhaled corticosteroids in children. Is there a 'safe' dosage?

Inhaled corticosteroids are effective for the treatment of asthma. Because of the appreciation of the importance of airway inflammation in the pathogenesis of the disease, these drugs are being used more frequently not only in severe but also in moderate asthma. Treatment rarely has to be stopped because of topical adverse effects since oropharyngeal candidiasis and dysphonia are uncommon in children. However, paediatricians need to remain alert for the possibility of systemic adverse effects. With sensitive techniques, dose-dependent adrenal suppression has been documented in children treated with inhaled steroids but generally this effect has no clinical relevance. Although suppression of short term growth velocity has been reported, long term studies have shown that when growth impairment occurs in a child with asthma it is more likely to reflect poor asthma control than the administration of inhaled corticosteroids. Calcium supplementation may be necessary in children with asthma treated with inhaled steroids since this treatment may cause reduction in osteocalcin, a marker of osteoblast activity and bone formation. Other systemic adverse effects have been reported in case reports. The use of a large spacer device has been shown to reduce the incidence of both topical and systemic adverse effects from inhaled steroids and their use should be encouraged. In any child with asthma who really needs inhaled steroids, the lowest dose possible should be prescribed; however, the mistake of prescribing doses too low to be therapeutically effective should be avoided.

Safety of high-dose inhaled corticosteroids

Inhaled corticosteroids are being given to more patients, at increasing doses and for longer periods of time. This has led to renewed concern about side-effects, particularly when higher doses (> 1 mg day-1) are used. The side-effects of particular concern are adrenocortical suppression, bone resorption, decreased growth in children, skin thinning and cataract formation. Changes in adrenocortical function are seen in a small proportion of patients given doses of 1-2 mg day-1. Long-term studies of the effect of inhaled corticosteroids on bone density are not available. Cross-sectional studies of bone density have been performed, but confounding variables, such as previous courses of oral corticosteroids and poor matching of control groups, make the studies difficult to interpret. Short-term effects on markers of bone turnover have been demonstrated, but their relevance to the long-term risk of osteoporosis is unclear. Studies reporting an increased incidence of skin changes and cataract formation are difficult to interpret because of confounding variables and inadequate control groups. Further studies of the long-term side-effects of inhaled corticosteroids are now required to enable prescribers to judge better the relative benefits and risks of this important asthma therapy.

A comparative study of the efficacy of beclomethasone dipropionate delivered from a breath activated and conventional metered dose inhaler in asthmatic patients

In order to overcome the problem of poor co-ordination with the use of the conventional press and breathe metered dose inhaler, a breath-activated inhaler ('Autohaler' inhalation device) has been developed. The clinical response to equal doses of beclomethasone dipropionate administered from the 'Autohaler' device and the conventional metered dose inhaler was compared in 36 stable asthmatic patients receiving regular inhaled beclomethasone dipropionate. The study was performed using a double-blind, double-dummy crossover design. Each treatment was given for 4 weeks. Objective and subjective measures of asthma severity were compared in the second 14 days of each treatment period, with clinical equivalence defined as a difference of 20% or less in the adjusted mean values for the 30 patients with data from both treatment periods. Equivalence at the +/- 5% level was found in the objective measures of pre-bronchodilator FEV1 (p < or = 0.001); post-bronchodilator FEV1 (p < 0.001); morning and evening peak expiratory flow rate (both p < or = 0.001). Patient diary cards established there was equivalent usage of inhaled bronchodilator, and equivalent symptom scores for daytime disability and daytime and night-time breathlessness. The results show that, in stable asthmatics, treatment with beclomethasone dipropionate is clinically equivalent when delivered by the 'Autohaler' device or the conventional metered dose inhaler used efficiently.

Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma

BACKGROUND

Relapse after the treatment of acute asthma in the emergency room is common (occurring in 25 to 30 percent of cases) and is not accurately predicted by any available measurements. We studied the usefulness of prednisone in reducing this high rate of relapse.

METHODS

One hundred twenty-two patients treated in the emergency room for acute exacerbations of asthma were assigned in a randomized, double-blind fashion to receive at discharge either prednisone for eight days (the dose being tapered from 40 to 0 mg per day) or matching placebo. Ninety-three were subsequently discharged from the emergency room and participated in the trial. On days 1, 7, and 14 after discharge, the patients were assessed during home visits with spirometry and diary-card review; they were contacted by telephone on day 21. Relapse was defined as an unscheduled medical visit occasioned by the patient's perceived need for further asthma treatment.

RESULTS

The overall risk of relapse was significantly lower in the prednisone group (P less than 0.05), with a significantly reduced rate of relapse during the first 10 days of follow-up (3 of 48, as compared with 11 of 45 in the placebo group; P less than 0.05). Thereafter (days 11 through 21), there was no further significant difference in relapse rates between treatment groups (five in the prednisone group and six in the placebo group). During the first week after discharge, patients receiving prednisone reported significantly lower mean (+/- SD) daily symptom scores for shortness of breath (1.4 +/- 0.4 vs. 2.5 +/- 0.4, P less than 0.01) and less frequent use of an inhaled bronchodilator (5.2 +/- 0.5 vs. 6.9 +/- 0.2 puffs per day, P less than 0.05) than patients receiving placebo. Subsequently, symptom scores and bronchodilator use were similar in the two groups.

CONCLUSIONS

A short course of prednisone reduced early relapse rates after the treatment of acute asthma in the emergency room, an effect limited to the period of steroid administration.

A study of the mechanism of the antiasthmatic action of inhaled budesonide

Inhaled antiasthmatic steroids have been assumed and yet never proved to exert their antiasthmatic effect by topical action in the airways. We tested the hypothesis that the efficacy of inhaled budesonide (BUD) might be due instead to its systemic activity after absorption. We compared inhaled and oral BUD with doses selected to ensure higher peak plasma levels and a greater area under the plasma concentration curve with the oral treatment. After pretreatment with beclomethasone to maximize asthma control, 47 adults with asthma were randomized to receive 0.4 mg of inhaled BUD per day (n = 16) or 1.4 mg of oral BUD per day (n = 15), or placebo (n = 16) in double-blind fashion and then followed weekly until asthma relapsed or for 8 weeks if no relapse occurred. "Relapse" was defined as a drop in the mean peak expiratory flow rate greater than 2 SEM below the mean during the baseline week before switching to the test drugs. The time to relapse was the primary outcome variable. Time to relapse was longer with inhaled than with oral BUD (medians, 22 versus 7.9 days; p = 0.003) or placebo (medians, 22 versus 9 days; p = 0.004). Oral BUD and placebo did not differ (p = 0.41). The morning serum cortisol levels remained normal during all three treatments. Thus, at conventional dosage the antiasthmatic effect of inhaled BUD may be fully explained by a local intrapulmonary action.

Adverse effects of inhaled corticosteroids

Corticosteroids have a significant role in the management of asthma due to their powerful anti-inflammatory actions. However, when given orally, they cause significant and unwanted side-effects. Early attempts to circumvent these side-effects were largely unsuccessful. Recently, new synthetic corticosteroids have been developed that have powerful topical action but weak generalised effects due to rapid systemic metabolism. These new compounds provide adequate control of airways' obstruction in almost all asthmatics. Oral candidiasis may occur but can generally be controlled by adjusting the frequency of dosage and changing delivery systems. In high doses, there is biochemical evidence of adrenal suppression, but the clinical importance of this is not yet clear and there is no evidence of a significant effect on growth in children. High dose inhaled corticosteroids have been shown to affect biochemical indices of bone turnover in the short term. The long term clinical consequences of this are still under evaluation. Inhaled corticosteroids have provided a significant advance in the management of asthma, but physicians need to remain alert for the possibility of systemic side effects when used in high doses for long periods of time.

The role of inhaled steroids in the treatment of asthma

The role of corticosteroids as anti-inflammatory agents is examined. A review of the evidence shows that inhaled corticosteroids are not entirely free of side effects. However, their risk:benefit ratio is clearly better than that of systemic steroids or under-treatment. There appears to be little to choose between different inhaled corticosteroids in terms of clinical usefulness. The preference of many physicians for using inhaled corticosteroids or theophylline as first-line drugs in the treatment of asthma is questioned. New studies have shown cromolyn sodium to be equally effective as theophylline, but much safer. The widely held belief that cromolyn sodium is not effective in adults is incorrect. Although the response in children is much better, cromolyn sodium is still beneficial in many adults. Inhaled corticosteroids are more potent than cromolyn sodium, but in the author's opinion cromolyn sodium is still the preferred first-line agent because of its greater safety.

A self management plan in the treatment of adult asthma

To determine whether routine assessment of peak expiratory flow (PEF) in association with a self management plan based on inhaled corticosteroid use is effective in the management of chronic asthma, 36 consecutive adult patients with asthma attending an outpatient chest clinic were admitted to an open prospective study. Patients were treated with inhaled salbutamol and beclomethasone dipropionate in an attempt to achieve normal lung function. Each patient had a "potential normal value," which was either the predicted normal or the maximum PEF value achieved by the patient, whichever was the higher. Patients measured PEF at home and if it fell by more than 30% from the potential normal value the dose of beclomethasone was doubled until PEF returned to the potential normal value, then continued at 20 mg/day for the same number of days. If PEF fell to below 150-200 l/min patients were asked to obtain emergency medical assistance. In the 30 patients who completed the trial the six months before and the six months after intervention with the self management plan were compared. There was a substantial improvement in both subjective and objective measurements of asthma severity, with a significant reduction in nights woken, days lost from work, and requirement for oral corticosteroids and a significant increase in baseline lung function. Routine measurement of PEF in association with a self management plan appears to be effective in reducing symptoms of asthma and improving lung function.

Corticosteroid-induced cataracts

The association linking corticosteroid therapy with the development of posterior subcapsular cataracts has been well documented. These drugs are widely used therapeutically, principally to capitalize on their ability to inhibit inflammatory responses. The literature on corticosteroid-induced posterior subcapsular cataracts is reviewed here. Data from the previously published series and individual lens susceptibility to corticoids do not allow the establishment of a direct factor relating cataract formation to corticosteroid dose and the duration of therapy; however, significant progress has been made in elucidating the mechanism by which corticoids bring about the development of these opacities. Exploration into the development of these lesions has shed light on the similarities these opacities share with other cataracts, especially with regard to location and pathogenesis.

Long-term safety and efficacy of budesonide nasal aerosol in perennial rhinitis. A 12-month multicentre study

A long-term safety study of intranasally administered budesonide, a topical glucocorticoid, has been performed. 104 patients with perennial rhinitis, allergic or non-allergic, participated in a multicentre study in seven ENT-clinics utilising an identical protocol. A budesonide dosage of 400 micrograms/day was used as starting dose, but the patients were at liberty to reduce the daily dose to 200 micrograms. The patients were observed at intervals up to 12 months. At the entry and follow-up visits the following parameters were recorded: rhinoscopic findings, nasal symptom scores, blood chemistry, hematology, urinalysis and determination of plasma cortisol levels before and after stimulation with ACTH (Synacthen). Nasal biopsies taken from 50 of the patients at the beginning and completion of the study were examined in a blinded way by an independent pathologist. The analysis revealed no histopathological changes of the nasal mucosa. At rhinoscopy no signs of atrophy or candida were reported. Lividity of the nasal mucosa was significantly reduced during the trial, which was also the case for nasal congestion and secretion. All nasal symptom parameters assessed by the patients were significantly reduced from baseline during the follow-up period. No clinically significant changes in the hematological and blood chemistry parameters were observed. Plasma cortisol analysis before and after challenge with ACTH revealed no influence on the hypothalamic pituitary adrenal axis. No tachyphylaxis was observed; on the contrary, there was a clear tendency for reduction of the daily dose of budesonide necessary to keep the patients symptom-free.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of anti-asthmatic drugs. Do they affect sports performance?

Recent major advances in pharmacological management have provided asthmatics with a satisfactory range of drugs to control asthma. These include sodium cromoglycate (cromolyn sodium), H1-antagonists, belladonna alkaloids, methyl xanthines, glucocorticoids and beta 2-adrenoceptor stimulants. Despite the tendency for most asthmatics to develop bronchoconstriction after exercise, sport and physical activity are now accepted as valuable in the overall management of patients with asthma. Thus, control of exercise-induced asthma (EIA) is essential, if asthmatics are to participate safely in physical activity and without respiratory disadvantage in competitive sport. Fortunately, inhibition or minimization of exercise-induced asthma may be achieved in most asthmatics by pre-exercise aerosol beta 2-agonists supplemented if necessary by sodium cromoglycate and/or theophylline. Regular medication as required to attain and maintain normal ventilatory function throughout each day is the objective in all patients with asthma and appears to be a prerequisiste to control exercise-induced asthma. The introduction of anti-doping controls into high performance sport has presented added difficulties for the asthmatic athlete. Although not always so, currently all of the classes of drugs previously noted are acceptable for the treatment of asthma and exercise-induced asthma. Anomalies may exist in the banning of 2 beta 2-adrenoceptor agonists, fenoterol and orciprenaline (metaproterenol). All sympathomimetic amines with alpha- or predominantly beta-stimulation are banned. The perpetuation of the need to report the use of beta 2-agonists prior to competition appears unnecessary. Although relatively little specific research has been undertaken, there is minimal evidence to suggest that asthmatics can derive any additional ergogenic advantage from medication to control asthma and exercise-induced asthma. beta 2-agonists, sodium cromoglycate and glucocorticoids administered by the aerosol route are not considered to be ergogenic. Some doubts have been raised concerning theophylline and its enhancement of both cardiac and respiratory muscle function. Investigations as to the validity of the suggestion that theophylline could augment physical performance appear warranted. It is reported that some athletes may be unnecessarily taking oral and perhaps parenteral glucocorticoids to obtain certain side effects. Any decision to ban these agents except for aerosol or local use could be supported.

Twice or four times daily beclomethasone dipropionate in mild stable asthma?

A double-blind cross-over study lasting 16 weeks was conducted to establish if a twice daily regimen of beclomethasone dipropionate (BDP) was as effective in controlling asthma as a four times daily regimen. The patient's need for inhaled steroids (100 mcg BDP qds) was confirmed prior to entering the study by deterioration of peak expiratory flow rates and/or increased bronchodilator usage during a single-blind placebo period of 6 weeks. Thirty six asthmatics were eligible to enter the study and completed both treatment periods. Daily record cards of symptom scores, four times daily peak expiratory flow rate measurements and inhaled bronchodilator usage were recorded throughout the study. There was no significant difference between the mean PEFR measurements taken four times each day and the variability in PEFR, between the two treatment groups. Symptom scores for cough, wheeze, breathlessness and overall disability also showed no significant difference. Symptomatic inhaler usage for the two groups was similar. Lung function measurements of FEV1, FVC and VC were almost identical; FEV1 being 2.1 l on twice daily regimen and 2.2 l on four times daily regimen. A slight variation was observed in PEFR taken at the end of each treatment period at the clinic visits, being 361 l/min on twice daily and 380 l/min on four times daily drug dosage. In stable asthmatics, the control of asthma measured both symptomatically and by daily lung function was independent of dosing schedule, but twice daily treatment may well lead to better compliance.

Corticosteroid aerosols in the treatment of asthma

Since the 1950s, corticosteroid aerosols have proved useful in the treatment of asthma. Although their precise mechanism of action is not known, these topical agents have beneficial antiinflammatory and decongestive effects on the bronchial tree in both the allergic and nonallergic forms of this disease. Four of the newer aerosolized steroids--beclomethasone dipropionate, triamcinolone acetonide, flunisolide and budesonide--have been evaluated in clinical trials. The last drug is still investigational. Their side effects are minimal, the major ones being oral candidiasis and dysphonia. They are most effective when used prophylactically and should not be administered during acute asthmatic attacks, as insufficient amounts of drug are inhaled when the airways are obstructed. Patients must be instructed in the correct techniques of administering steroid aerosols to ensure optimal therapy.

Inhaled therapy reduces morning dips in asthma

14 asthmatic patients with nocturnal symptoms and morning dips in peak expiratory flow rate (PEFR) were treated with regular inhaled salbutamol for 1 or 2 weeks, followed by regular inhaled beclomethasone dipropionate, in addition to salbutamol, for a further 2 weeks. Mean PEFR rose to normal values in all but 1 patient. Morning dips in PEFR were substantially reduced in 8 patients. There was an equivalent rise in mean PEFR in the other 6 patients, but their morning dips did not improve. Inhaled salbutamol reduced the dips in the responsive patients, but addition of inhaled steroid produced further improvement. Inhaled beta agonist alone improved mean PEFR in these patients, but inhaled steroids produced most of the improvement in the other subgroup. No patient experienced side-effects. Thus mean PEFR can be improved and morning dips in PEFR reduced in a high proportion of asthmatic patients by the use of regular inhaled therapy without resorting to less-well-tolerated oral agents.

Nasal respiratory resistance and head posture: effect of intranasal corticosteroid (Budesonide) in children with asthma and perennial rhinitis

The influence of mouth breathing on craniofacial development has previously been demonstrated. Recent investigations do indicate, however, that head posture also might be related to craniofacial morphology. The aim of the present study was to analyze the effect of a topical steroid spray (Budesonide) on nasal respiratory resistance and head posture in children with asthma and nasal obstruction. Thirty-seven children, 8 to 15 years of age, with bronchial asthma, perennial allergic rhinitis, and subjectively assessed mouth breathing were selected for the study. Rhinomanometric and cephalometric analyses were performed. Head posture was defined as the position of the head relative to the cervical column and to the true vertical. After the first examination the children were randomly allocated to two groups, of which one group was treated intranasally with Budesonide (N = 18) and the other with placebo (N = 19), for a double-blind study. After one month of treatment, there was a statistically significant decrease in nasal resistance (p less than 0.001) and an increased flexing of the head (p less than 0.01) (paired t tests) in the children under active treatment. No significant changes were seen in the placebo group. The results indicate that Budesonide nasal spray is capable of reducing nasal obstruction in allergic children and that a reduced nasal resistance leads to a decrease in craniocervical angulation. The clinical importance of these results is yet to be clarified.

Effect of a timed interval between inhalation of beta-agonist and corticosteroid aerosols on the control of chronic asthma

A randomised double-blind crossover study was undertaken in 25 patients with variable airflow obstruction to assess the benefit of separating the inhalation of beta-agonist aerosols and corticosteroid aerosols by a timed interval of more than five minutes. Twenty-two patients (11 men and 11 women) completed 12 weeks of study; they inhaled 200 micrograms salbutamol followed either immediately or after a timed interval by 100 micrograms beclomethasone dipropionate two to four times daily. Morning and evening peak expiratory flow rates, symptom scores, additional beta-agonist inhaler usage, and subjective responses on a visual-analogue scale were recorded throughout. Results from the two last four-week periods, with and without the interval between drugs, were analysed. No differences were found. It is concluded that the theoretical benefit of delaying corticosteroid inhalation until optimum bronchodilatation has been achieved with a beta-agonist is not demonstrable in outpatient practice.

The recent history of the treatment of asthma: a personal view

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Topical and systemic glucocorticoid potencies of budesonide and beclomethasone dipropionate in man

Topical anti-inflammatory (cutaneous "vasoconstriction") and systemic glucocorticoid (depression of plasma cortisol and changes in differential WBC count) potencies of the two glucocorticoids budesonide and beclomethasone dipropionate (BDP) were compared in human volunteers. After topical application, budesonide was 2-3 times more potent than BDP in inducing "vasoconstriction". After oral administration, on the other hand, budesonide was 2-4 times less potent than BDP in depressing plasma cortisol and changing the total or differential WBC. After inhalation, too, significant differences in favour of budesonide were noted, but the divergence between the drugs was less pronounced. The improved relationship between the topical and systemic glucocorticoid effects of budesonide makes it a promising alternative for aerosol treatment in asthma.

The use of cultures and immunologic procedures to predict oropharyngeal candidiasis in patients on steroid aerosols

Sixty-seven asthmatic individuals treated with either beclomethasone diproprionate or flunisolide were sequentially evaluated for up to 32 months to determine the incidence of oropharyngeal candidiasis as well as laboratory parameters which might be predictive of this complication. Throat cultures and measurements of Candida antibody by immunodiffusion and radioimmunoassay were performed and compared over time and treatment groups. Unlike other studies, pre-treatment Candida precipitins did not predict increased risk for clinical thrush nor did quantitative determinations of Candida antibody. Those patients with positive cultures pre-trial, however, had a significantly higher incidence of clinical thrush than those with negative cultures (P less than 0.01). No significant changes occurred over time or between drugs for any of the parameters. Symptomatic thrush, however, was slightly more common in those patients treated with beclomethasone.

Aerodynamic size distribution, hygroscopicity and deposition estimation of beclomethasone dipropionate aerosol

Aerodynamic size distribution and aerodynamic mass per dose of beclomethasone dipropionate aerosol were measured at 24 and 95% relative humidity. At high humidity, the count median aerodynamic diameter was unchanged, mass median aerodynamic diameter increased from 2.01 micrometer to 2.68 micrometer, particle number/dose from 41.3 x 106 to 78.3 x 106, and aerodynamic mass per dose from 23.7 to 60.0 microgram. The quantity of active ingredient estimated to be in the 23.7 microgram aerodynamic mass at low humidity was 19.7 microgram. From data previously available describing average deposition fraction as a function of aerodynamic diameter, 6.7 microgram or 13% of the total dose of 50 microgram produced by the metered dose canister would be expected to deposit in the lower respiratory tract.

Beclomethasone dipropionate in asthma: a comparison of two methods of administration

Beclomethasone dipropionate inhaled as a dry powder in doses of 200 microgram four times a day was compared with the usual dose of 100 microgram four times a day from a pressurized aerosol in 65 patients with asthma who used pressurized aerosols correctly. Each treatment was given for an eight-week period. The dry powder did not show any clinically significant advantage over the aerosol in terms of ventilatory function as measured by FEV1 and the daily peak flow measurements during both treatments did not differ. The incidence of oral candidiasis was low and no other side-effects were encountered. It was concluded that beclomethasone dipropionate in dry powder form was as effective as aerosol in the treatment of asthma.

Beclomethasone dipropionate aerosol in the treatment of asthma in steroid-independent children

Sixty-eight steroid-independent children, whose asthma was poorly controlled by bronchodilators and other anti-asthmatic drugs, were treated for six weeks with 200 to 400 mcg per day of beclomethasone dipropionate aerosol. Symptoms of wheezing, blockage, and cough, reported by the children in a daily diary, improved in 80% of cases. Use of other anti-asthmatic medications, which the children were free to modify as they wished, decreased. Objective measurements of pulmonary function, VC, FEV1, and FEV%, evaluated by weekly spirometry, also improved in almost 80% of cases. The dosages used here had no effect on early morning plasma cortisol levels and none of the children developed signs of oral candidiasis.

Effects of inhaled beclomethasone dipropionate and alternate-day prednisone on pituitary-adrenal function in children with chronic asthma

Two corticosteroid regimens, alternate-day prednisone and inhaled beclomethasone dipropionate, have been more acceptable than daily oral corticosteroids for treatment of chronic asthma. To compare the effect of these regimens on hypothalamic-pituitary-adrenal function, 20 children with asthma were evaluated while receiving 20 to 40 mg of prednisone on alternate mornings or 400 to 800 microgram per day of inhaled beclomethasone dipropionate in divided daily doses; seven children requiring only non-corticosteroid medication served as controls. Early-morning serum cortisol concentration, urinary free-cortisol excretion and the 11-desoxycortisol response to metyrapone were decreased to a similar degree among children receiving both corticosteroid regimens in comparison with the control patients and were lowest when alternate-day prednisone and inhaled beclomethasone dipropionate were given together. Thus, inhaled beclomethasone dipropionate appears similar to alternate-day prednisone in its effect on hypothalamic-pituitary-adrenal function when used alone; the effect is additive when the two are used together.

Severe ventilatory failure in asthma in children. Experience of 13 episodes over 6 years

During the 6-year period from 1 October 1971 to 30 September 1977, 13 (about 1%) of 1225 admissions to hospital with asthma developed severe ventilatory failure (peak arterial PCO 2 greater than 8 kPa). Mean age was 4.1 years (2.3--7.9), and on average each patient had been admitted to hospital on 5 occasions during the preceding year. 11 gave a family history of asthma or a personal history of associated allergies. A viral upper respiratory tract infection was the commonest precipitant of wheeze, and in 7 patients the duration of wheeziness before admission to hospital was 12 hours or less. Six (0.5%) patients were treated by mechanical ventilation and all survived. The changing patterns of management during the study period are reviewed.

Combined therapy with salbutamol and beclomethasone inhalers in chronic asthma

A double-blind cross-over trial was carried out to compare the effect of identical placebo with that of salbutamol inhalers used 30 min before inhalation of 100 microgram of beclomethasone dipropionate (B.D.P.) in 18 chronic asthmatics over two consecutive 4-week periods. The salbutamol and B.D.P. combination resulted in a significant improvement in the peak expiratory flow-rate and F.E.V.1, significantly less use of the rescue inhaler, and better control.

Modern treatment of bronchial asthma

Various biochemical mediators and autonomic events lead to symptom-causing pathological changes in asthma attacks, that is, mucosal edema, mucous gland hypersecretion, and bronchial smooth muscle contraction. The discovery of alpha and beta adrenergic receptors, and the observation that cyclic AMP is the intracellular effector in cells stimulated by various hormones, led to a better understanding of the mechanism of action of medications of asthma. Emergence evaluation, in addition to history, physical findings, and physiological status, should include prior asthma history, physical findings, and physiological status, should include prior asthma history. Initial emergency therapy in patients with a history suggesting responsiveness to simple measures includes subcutaneous epinephrine, 0.2 to 0.5 mg, or terbutaline sulfate, 0.25 mg. Also, the patient may benefit from inhalation of an aerosolized bronchodilator. Patients who do not respond to initial treatment in three to four hours or who deteriorate, should be hospitalized. Hospitalized asthma patients should be constantly observed and monitored. The emergency treatment should be continued vigorously. Corticosteroid therapy should be started upon admission. The response rate to therapy in the hospitalized asthmatic is highly variable. Outpatient management involves patient education in the nature of asthma and in the fact that multiple drugs and frequent changes in therapy may be required to bring the symptoms under control.