For mild asthma, less may be more

An estimated 4 million adults in the United States with a mild form of asthma may not need to take daily steroid doses but can instead use the drug only as needed to control symptoms, according to a new study supported by the National Institutes of Health.

The change would make drug use more convenient, minimize side effects from the powerful drugs and possibly save the nation as much as $2 billion per year.

The study results do not apply to the 10 million adults with more severe forms of the disease, but "for some adults with long-standing mild persistent asthma, choosing not to take daily medications might be OK," said Dr. Elliott Israel of Brigham and Women's Hospital in Boston, the co-leader of the study.

Israel noted that many such patients are already skipping the medicine routinely. Only about 30 percent of prescriptions for the daily steroids are refilled, apparently because patients don't think it makes them feel better. The findings published in today's New England Journal of Medicine appear to validate that belief, he said.

Asthma is considered mild and persistent when individuals have acute symptoms, such as wheezing, coughing or chest tightness, between two and five times a week, or are awakened by asthma more than twice a month. Perhaps a third of the 14 million U.S. adults and 6 million children with asthma have this form.

Children were not included in the study.

Treatment guidelines published in 1997 indicate that patients with this form should use an inhaled steroid called budesonide (marketed as Rhinocort) daily to control their disease and an inhaled bronchodilator called Albuterol to treat symptoms as they occur. An alternative is daily use of another drug, zafirlukast (marketed as Accolate).

Those guidelines were based on earlier studies that suggested daily use of the drugs prevented long-term damage to the lungs. But closer analysis of the studies indicated that many of the patients did not have mild persistent asthma, said Dr. Homer Boushey of the University of California, San Francisco, the study's other co-leader.

In the new trial, 225 adults with confirmed mild persistent asthma were given either daily budesonide, zafirlukast or a placebo, and allowed to use a bronchodilator as needed. All patients were also given budesonide and taught how to administer a 10-day course of the drug if they suffered an outbreak of symptoms.

At the end of the year, "all three groups were far more alike than they were different," Boushey said. Their lung functions were similar, they had about the same frequency of severe attacks, and they all showed little or no evidence of lung damage.