Artikel:
Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations
NEJM 2018, March 8
Vi har nok alle stået med et astmabarn med en begyndende forværring af sine lungesymptomer. Det kunne være, at du tænkte: ”Burde man ikke gøre noget?” ”Hvad med at øge den vanlige behandling, for hvis lidt behandling er godt, når man er lidt syg, er meget behandling så ikke godt, når man er meget syg?”
Åbenbart ikke! Et nyt randomiseret dobbeltblindet, kontrolleret studie, der netop er udgivet i NEJM, viser, at der ikke er nogen positiv effekt ved at 5-doble den vanlige inhalationssteroid behandling, når der er optræk til exacerbation hos astmabørn.
Tidligere har der været en tendens til, at man øgede inhalationssteroider ved luftvejssymptomer hos astmabørn. Denne kutyme er ikke helt nem at udrydde, hvorfor studier, der via RCT’s, klart viser at disse behandlingstiltag ingen positiv effekt har, er af stor betydning. Med disse i hånden har vi evidens, der kan hjælpe med at undgå unødvendig og potentiel skadelig behandling af børn.
Resultaterne er faktisk også i tråd med de danske behandlingsrekommandationer for børneastma, hvor det klart fremgår, at anfaldsbehandling består af korttidsvirkende β2 agonister og ikke inhalationssteroider (http://www.regioner.dk/media/1886/astma-primaer-sektor-beh-juni-2015.pdf).
Til de audio-visuelle kan nævnes at NEJM har lavet en fin lille video af studiet, hvor hovedtrækkene gennemgås (http://www.nejm.org/do/10.1056/NEJMdo005262/full/?requestType=popUp&relatedArticle=10.1056%2FNEJMoa1710988).
Endvidere er der i Medscape, lavet en ganske udmærket journalistisk gennemgang af studiet og baggrunden herfor (https://www.medscape.com/viewarticle/893486#vp_1)
God fornøjelse med studiet, Mikel Alberdi-Saugstrup
N Engl J Med 2018; 378:891-901, DOI: 10.1056/NEJMoa1710988
Abstract
BACKGROUND
Asthma exacerbations occur frequently despite the regular use of asthma-controller therapies, such as inhaled glucocorticoids. Clinicians commonly increase the doses of inhaled glucocorticoids at early signs of loss of asthma control. However, data on the safety and efficacy of this strategy in children are limited.
METHODS
We studied 254 children, 5 to 11 years of age, who had mild-to-moderate persistent asthma and had had at least one asthma exacerbation treated with systemic glucocorticoids in the previous year. Children were treated for 48 weeks with maintenance low-dose inhaled glucocorticoids (fluticasone propionate at a dose of 44 μg per inhalation, two inhalations twice daily) and were randomly assigned to either continue the same dose (low-dose group) or use a quintupled dose (high-dose group; fluticasone at a dose of 220 μg per inhalation, two inhalations twice daily) for 7 days at the early signs of loss of asthma control (“yellow zone”). Treatment was provided in a double-blind fashion. The primary outcome was the rate of severe asthma exacerbations treated with systemic glucocorticoids.
RESULTS
The rate of severe asthma exacerbations treated with systemic glucocorticoids did not differ significantly between groups (0.48 exacerbations per year in the high-dose group and 0.37 exacerbations per year in the low-dose group; relative rate, 1.3; 95% confidence interval, 0.8 to 2.1; P=0.30). The time to the first exacerbation, the rate of treatment failure, symptom scores, and albuterol use during yellow-zone episodes did not differ significantly between groups. The total glucocorticoid exposure was 16% higher in the high-dose group than in the low-dose group. The difference in linear growth between the high-dose group and the low-dose group was −0.23 cm per year (P=0.06).
CONCLUSIONS
In children with mild-to-moderate persistent asthma treated with daily inhaled glucocorticoids, quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations or improve other asthma outcomes and may be associated with diminished linear growth. (Funded by the National Heart, Lung, and Blood Institute; STICS ClinicalTrials.gov number, NCT02066129.)