D'Urzo Anthony D
Department of Family and Community Medicine, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada.
Treat Respir Med. 2006;5(6):385-91. doi: 10.2165/00151829-200605060-00003.
Despite aggressive fixed-dose (FD) combination therapy with inhaled glucocorticosteroids (ICS) and long acting beta(2)-adrenoceptor agonists (LABA), many patients with asthma remain suboptimally controlled, based on the need for rescue therapy and rates of severe exacerbations. The strategy of adjustable maintenance dosing (AMD) involves adjustment of the maintenance dose, (using a single combination [budesonide/formoterol] inhaler, Symbicort((R))) in response to variability of asthma control over time. The AMD strategy, like the FD approach, involves the use of a short-acting beta(2)-adrenoceptor agonist (SABA) for rapid relief of bronchospasm. The dose-response characteristics of budesonide/formoterol make the AMD strategy a feasible option that cannot be exploited with the combination of salmeterol/fluticasone propionate (Advair((R))). Several studies suggest that the AMD strategy is superior to a FD approach in terms of overall asthma control.Budesonide/formoterol in a single inhaler is as effective as albuterol (salbutamol) for relief of acute asthma episodes, a feature that makes it possible to use this combination for both maintenance and reliever therapy without the need for the use of a SABA. The single-inhaler strategy has been shown to be safe and more efficacious than FD therapy. In particular, the COSMOS study has demonstrated that exacerbation burden is reduced more effectively when the combination (budesonide/formoterol) single inhaler is used for both maintenance and relief compared with FD therapy with salmeterol/fluticasone and albuterol for rescue in patients with moderate-to-severe asthma. These findings suggest that we will have to reconsider our definition of reliever therapy for patients that require long-term therapy with combination ICS and LABA.The concept of single-inhaler therapy represents a paradigm shift in asthma management that has been validated in several large studies involving thousands of patients. The single-inhaler strategy represents one of the most significant advances in asthma management in many years, and one that appears ideal for adoption in primary care.
尽管采用吸入性糖皮质激素（ICS）和长效β₂肾上腺素受体激动剂（LABA）进行积极的固定剂量（FD）联合治疗，但基于急救治疗的需求和严重加重发作的发生率，许多哮喘患者的病情仍未得到最佳控制。可调维持剂量（AMD）策略涉及根据哮喘控制随时间的变化来调整维持剂量（使用单一组合[布地奈德/福莫特罗]吸入器，信必可都保）。与FD方法一样，AMD策略也使用短效β₂肾上腺素受体激动剂（SABA）来快速缓解支气管痉挛。布地奈德/福莫特罗的剂量反应特性使AMD策略成为一种可行的选择，而沙美特罗/丙酸氟替卡松（舒利迭）组合则无法采用这种策略。多项研究表明，在总体哮喘控制方面，AMD策略优于FD方法。单一吸入器中的布地奈德/福莫特罗在缓解急性哮喘发作方面与沙丁胺醇一样有效，这一特性使得该组合可用于维持治疗和缓解治疗，而无需使用SABA。已证明单一吸入器策略比FD治疗更安全、更有效。特别是，COSMOS研究表明，与使用沙美特罗/丙酸氟替卡松和沙丁胺醇进行急救的FD治疗相比，对于中重度哮喘患者，使用（布地奈德/福莫特罗）单一吸入器进行维持和缓解治疗时，加重负担能得到更有效的减轻。这些发现表明，对于需要长期使用ICS和LABA联合治疗的患者，我们必须重新考虑缓解治疗的定义。单一吸入器治疗的概念代表了哮喘管理模式的转变，这已在涉及数千名患者的多项大型研究中得到验证。单一吸入器策略是多年来哮喘管理中最重要的进展之一，似乎非常适合在初级保健中采用。
