Capital Allergy and Respiratory Disease Center, Sacramento, California.
Doctor Evidence, Santa Monica, California.
Ann Allergy Asthma Immunol. 2020 Aug;125(2):163-170.e3. doi: 10.1016/j.anai.2020.04.006. Epub 2020 Apr 14.
Inhaled corticosteroids (ICSs) are recommended as first-line controller medications for persistent asthma. However, guidelines on the initial ICS doses, step-up and step-down algorithms, and when to switch to combination therapy vary.
To understand the ideal starting doses of ICS therapy based on current evidence and to systematically compare low, moderate, and high starting doses of ICSs as monotherapy and in combination with long-acting β-agonists with respect to efficacy and safety.
MEDLINE, Embase, and Cochrane databases were searched for relevant English-language articles published from 1980 to November 17, 2018. Randomized controlled trials with adult, steroid-naive, ICS-free (for ≥4 weeks) patients with asthma and a duration of 4 weeks or longer with an ICS treatment arm (monotherapy or combination therapy) were included. Separate fixed-effects Bayesian network meta-analyses were conducted on the extracted data for peak expiratory flow, forced expiratory volume in 1 second, nighttime rescue medication use, nighttime symptom score, and study withdrawal because of an adverse event.
A total of 31 randomized controlled trials were analyzed. All starting doses of ICSs were comparable with respect to nighttime rescue medication use, nighttime symptom score, change in forced expiratory volume in 1 second, and study withdrawal because of an adverse event. Significant improvement in morning peak expiratory flow was observed with high-dose ICSs and with low- and moderate-dose ICSs and long-acting β-agonists than with low-dose ICSs.
Overall, a high starting dose of ICSs had no additional clinical benefit in 3 of the 4 efficacy parameters compared with low or moderate ICS doses for controlling moderate to severe asthma but might have potential safety concerns.
吸入性皮质类固醇（ICSs）被推荐为持续性哮喘的一线控制药物。然而，关于初始 ICS 剂量、逐步升级和逐步降级算法以及何时转换为联合治疗的指南存在差异。
根据现有证据了解 ICS 治疗的理想起始剂量，并系统比较低、中、高起始剂量的 ICS 单药治疗和与长效β激动剂联合治疗在疗效和安全性方面的差异。
检索 MEDLINE、Embase 和 Cochrane 数据库，以获取 1980 年至 2018 年 11 月 17 日发表的相关英文文献。纳入成人、类固醇初治、ICS 自由（≥4 周）、哮喘患者、持续时间≥4 周且具有 ICS 治疗臂（单药治疗或联合治疗）的随机对照试验。对提取的数据进行独立固定效应贝叶斯网络荟萃分析，以评估峰值呼气流量、1 秒用力呼气量、夜间急救药物使用、夜间症状评分和因不良事件退出研究。
共分析了 31 项随机对照试验。所有 ICS 起始剂量在夜间急救药物使用、夜间症状评分、1 秒用力呼气量变化和因不良事件退出研究方面无差异。与低剂量 ICS 相比，高剂量 ICS 以及低剂量和中剂量 ICS 与长效β激动剂联合治疗可显著改善清晨呼气峰值流量。
总体而言，与低剂量或中剂量 ICS 相比，高剂量 ICS 在控制中重度哮喘的 4 项疗效参数中的 3 项中没有额外的临床获益，但可能存在潜在的安全性问题。
