Dosages for inhaled corticosteroids should be modified
British Thoracic Society asthma guidelines on the recommended
doses for inhaled corticosteroids should be modified, say researchers
from New Zealand.
The guidelines currently recommend that adults with
chronic asthma should take beclometasone and budesonide at doses of 800
to 2,000µg per day in a large volume spacer. The recommendation for fluticasone
propionate is for doses of 400 to 1,000µg per day. These recommendations
are largely pragmatic and are not based on strong scientific evidence,
say the researchers.
Dr Shaun Holt and colleagues, of the Wellington
asthma research group, conducted a meta-analysis of eight placebo-controlled,
randomised trials that had examined the efficacy of fluticasone at two
or more different doses in 2,324 patients (adolescents and adults). They
found that most of the therapeutic benefit of inhaled fluticasone was
achieved with a total daily dose of 100 to 250µg and that the maximum
effect was seen with a dose of about 500µg a day (BMJ, 2001;323:253).
In an accompanying commentary, Dr Andrew Herxheimer,
UK Cochrane Centre, says that the conclusion of the researchers is convincing
and important. However, he asks why it has taken so long to discover the
maximum useful dosage of fluticasone, which was first marketed in 1993.
“It is likely that the dose-response relations of
other drugs should be revisited. We need to identify the most important
of them and begin,” he adds (ibid, p256).
Professor Duncan Geddes, president of the British
Thoracic Society, said that the study was important, especially for clinicians
who did not follow the literature closely and who were still prescribing
inhaled steroids at higher doses than were strictly necessary. Professor
Geddes said that the next version of the BTS guidelines were being worked
on and that the results of this meta-analysis would be taken into account.
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