Creticos Peter S
Department of Medicine and Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, USA.
Drugs. 2003;63 Suppl 2:1-20. doi: 10.2165/00003495-200363002-00002.
Inhaled corticosteroids (ICSs) are recognized as the cornerstone of asthma therapy. They are considered to be the most effective anti-inflammatory medication currently available for the treatment of persistent asthma, regardless of its severity. Leukotriene receptor antagonists (LTRAs) are also used as initial maintenance therapy in patients whose asthma is uncontrolled by bronchodilators alone. There are now sufficient data available to allow a comparison of the relative effectiveness and cost-effectiveness of LTRAs and ICSs as initial maintenance therapy. The consensus from the studies reviewed in this article demonstrates that ICSs are more effective than LTRAs as initial maintenance therapy. In particular, studies on fluticasone propionate have shown that it was more effective than LTRAs in clinical outcomes: producing greater improvements in lung function and asthma control; as measured by either forced expiratory volume in 1 second (FEV1) or peak expiratory flow (PEF); by a greater reduction in daytime and night-time asthma symptoms; and short-acting beta2-agonist use. This superiority was also seen when patients were switched from an LTRA to fluticasone propionate. Similar findings have been demonstrated with beclomethasone dipropionate (BDP), showing that, in adults, this inhaled steroid also had a greater effect on pulmonary function and symptom scores than did LTRAs. Quality of life assessments showed that fluticasone propionate achieved improvements that were deemed to be clinically meaningful; these changes were significantly greater than those achieved with LTRAs. However, questionnaire-based patient preference studies comparing BDP with LTRAs showed that children and adolescents generally preferred an LTRA to BDP. A number of comparative analyses showed that inhaled fluticasone propionate is more cost-effective than either montelukast or zafirlukast; these analyses used cost per symptom-free day and cost per successfully treated patient as outcome measures, from the perspective of a third-party payer. In general, these results were supported by resource utilisation studies in real-world settings. Asthma treatment guidelines (e.g. GINA, 2002) recommend combination therapy with ICSs and a long-acting beta2-agonist as initial maintenance therapy if the disease is of sufficient severity. Studies that assessed the effectiveness, cost-effectiveness, and quality of life achieved with a salmeterol fluticasone propionate combination as initial maintenance therapy also showed it to be superior to LTRAs. In conclusion, in terms of efficacy and quality of life, fluticasone propionate is more effective than LTRAs as initial maintenance therapy and is associated with significantly lower healthcare costs and less frequent use of healthcare resources than LTRAs. There is also evidence to suggest that initial maintenance therapy with the combination of an inhaled steroid plus a long-acting beta-agonist bronchodilator may be a more effective option for the management of persistent asthma than treatment with a single-controller agent alone (ICS or LTRA).
吸入性糖皮质激素（ICSs）被公认为哮喘治疗的基石。它们被认为是目前可用于治疗持续性哮喘最有效的抗炎药物，无论哮喘严重程度如何。白三烯受体拮抗剂（LTRAs）也被用作初始维持治疗药物，用于那些仅使用支气管扩张剂无法控制哮喘的患者。目前已有足够的数据来比较LTRAs和ICSs作为初始维持治疗的相对有效性和成本效益。本文所综述研究的共识表明，ICSs作为初始维持治疗比LTRAs更有效。特别是，丙酸氟替卡松的研究表明，它在临床疗效方面比LTRAs更有效：在肺功能和哮喘控制方面有更大改善；通过第1秒用力呼气量（FEV1）或呼气峰值流速（PEF）来衡量；白天和夜间哮喘症状有更大程度的减轻；以及短效β2激动剂的使用减少。当患者从LTRA转换为丙酸氟替卡松时也观察到了这种优越性。二丙酸倍氯米松（BDP）也有类似的发现，表明在成年人中，这种吸入性类固醇对肺功能和症状评分的影响也比LTRAs更大。生活质量评估表明，丙酸氟替卡松实现了被认为具有临床意义的改善；这些变化明显大于LTRAs所实现的变化。然而，基于问卷的患者偏好研究比较BDP和LTRAs表明，儿童和青少年通常更喜欢LTRA而不是BDP。一些比较分析表明，吸入丙酸氟替卡松比孟鲁司特或扎鲁司特更具成本效益；这些分析从第三方支付者的角度，将每无症状天数的成本和每成功治疗患者的成本作为结果指标。总体而言，这些结果得到了现实环境中资源利用研究的支持。哮喘治疗指南（如2002年全球哮喘防治创议）建议，如果疾病严重程度足够，则将ICSs与长效β2激动剂联合作为初始维持治疗。评估沙美特罗丙酸氟替卡松联合作为初始维持治疗的有效性、成本效益和生活质量的研究也表明它优于LTRAs。总之，在疗效和生活质量方面，丙酸氟替卡松作为初始维持治疗比LTRAs更有效，并且与显著更低的医疗成本和比LTRAs更少的医疗资源使用相关。也有证据表明，吸入性类固醇加长效β激动剂支气管扩张剂联合作为初始维持治疗对于持续性哮喘的管理可能比单独使用单一控制药物（ICS或LTRA）是更有效的选择。
