Gibson Peter G, Powell Heather
Hunter Medical Research Institute, Department of Respiratory and Sleep Medicine, John Hunter Hospital, New South Wales, and University of Newcastle, Australia.
Curr Opin Pulm Med. 2006 Jan;12(1):48-53. doi: 10.1097/01.mcp.0000199808.64882.12.
This review examines the commencement of maintenance pharmacotherapy for asthma: inhaled corticosteroids alone or in combination with long-acting beta2 agonists.
A systematic review of randomized controlled trials has examined the starting dose of inhaled corticosteroids (high, moderate, low) and the dose regimen (step down versus constant) in asthma. There was no significant difference in key asthma outcomes for step down compared with a constant inhaled corticosteroid dose. There was no significant difference between high or moderate dose inhaled corticosteroid groups (n=11) for morning peak expiratory flow, symptoms and rescue medication use. There may be a benefit from high-dose inhaled corticosteroids for airway hyperresponsiveness. There was a significant improvement in peak expiratory flow and nocturnal symptoms in favour of a moderate inhaled corticosteroid dose compared with low-dose treatment. Long-acting beta2 agonists combined with inhaled corticosteroids as initial asthma therapy has been examined in a systematic review of nine randomized controlled trials. Inhaled corticosteroids combined with long-acting beta2 agonists led to significant improvements in forced expiratory volume in 1 s, morning peak expiratory flow, symptom score and symptom-free days but no difference in exacerbations requiring oral corticosteroids. A randomized controlled trial of patients with uncontrolled asthma found a benefit of escalating doses of salmeterol/fluticasone compared with fluticasone on asthma control.
Initial inhaled corticosteroid therapy should begin with a constant, moderate dose. Initial therapy with long-acting beta2 agonist and inhaled corticosteroids achieves superior improvement in symptoms and lung function, and at a quicker rate than inhaled corticosteroids alone. There is no benefit in terms of reduced exacerbations unless an escalating inhaled corticosteroid dose strategy is used.
本综述探讨哮喘维持药物治疗的起始方案：单独使用吸入性糖皮质激素或联合长效β2受体激动剂。
一项对随机对照试验的系统评价考察了哮喘患者吸入性糖皮质激素的起始剂量（高、中、低）和剂量方案（逐步减量与持续给药）。与持续吸入糖皮质激素剂量相比，逐步减量在关键哮喘结局方面无显著差异。高剂量或中剂量吸入糖皮质激素组（n = 11）在晨间呼气峰值流速、症状及急救药物使用方面无显著差异。高剂量吸入糖皮质激素可能对气道高反应性有益。与低剂量治疗相比，中剂量吸入糖皮质激素在呼气峰值流速和夜间症状方面有显著改善。一项对9项随机对照试验的系统评价考察了长效β2受体激动剂联合吸入性糖皮质激素作为初始哮喘治疗方案的效果。吸入性糖皮质激素联合长效β2受体激动剂可使1秒用力呼气容积、晨间呼气峰值流速、症状评分及无症状天数显著改善，但在需要口服糖皮质激素的加重发作方面无差异。一项针对未控制哮喘患者的随机对照试验发现，与氟替卡松相比，沙美特罗/氟替卡松剂量递增对哮喘控制有益。
初始吸入性糖皮质激素治疗应以持续的中剂量开始。长效β2受体激动剂与吸入性糖皮质激素联合进行初始治疗在症状和肺功能方面有更优改善，且比单独使用吸入性糖皮质激素起效更快。除非采用递增吸入性糖皮质激素剂量策略，否则在减少加重发作方面并无益处。
