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July 12, 1995, Vol 274, No. 2 >
ARTICLE | July 12, 1995

Periodic Treatment Regimens With Inhaled Steroids in Asthma or Chronic Obstructive Pulmonary Disease: Title and subTitle BreakIs It Possible? FREE

Constant P. van Schayck, PhD; Paul J. J. A. van den Broek, MD; Joost J. den Otter, MD; Cees L. A. van Herwaarden, MD, PhD; Johan Molema, MD, PhD; Chris van Weel, MD, PhD
[+] Author Affiliations

Reprint requests to Department of General Practice/ Family Practice, University of Nijmegen, PO Box 9101, 6500 HB Nijmegen, the Netherlands (Dr van Schayck).


JAMA. 1995;274(2):161-164. doi:10.1001/jama.1995.03530020079036
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References

Objective.  —To determine whether inhaled corticosteroids can be discontinued in the stable phase of asthma or chronic obstructive pulmonary disease (COPD) or if this therapy should be continued.

Design.  —Nonrandomized open uncontrolled 5-year trial.

Setting.  —Prospective study in general practice.

Patients.  —Forty-eight patients with steroid-dependent asthma or COPD who had shown a decline in forced expiratory volume in 1 second (FEV1) of at least 80 mL per year and at least one exacerbation per year during the first 2 years of bronchodilator treatment. Subjects were treated additionally with inhaled steroids for another 2 years and were finally given the option to stop using steroids. Sixteen patients were willing to stop using beclomethasone and were studied for another year. No recruitment bias took place in this consecutive sample in the fifth year of follow-up. Two of 16 patients developed carcinomas and dropped out.

Interventions.  —Two years of bronchodilator treatment alone (400 μg of salbutamol or 40 μg of ipratropium bromide four times daily), followed by 2 years of additional inhaled corticosteroid treatment (400 μg of beclomethasone two times daily), and finally 1 year of bronchodilator treatment alone.

Main Outcome Measures.  —Decline in lung function (FEV1), change in bronchial hyperresponsiveness, indicated by a provocative concentration of histamine causing a 20% fall in FEV1 (PC20), morning peak expiratory flow rate (PEFR), diurnal PEFR, week-to-week variation of PEFR, bronchial symptoms, and exacerbations.

Results.  —The course of FEV1 during the year in which beclomethasone was discontinued was not significantly different when compared with the 2-year period of beclomethasone treatment. Neither did the course of PC20, morning PEFR, diurnal PEFR, symptom score, and exacerbation rate change. Only the week-to-week variation of the PEFR increased after discontinuing steroids.

Conclusions.  —Discontinuing inhaled steroids is possible in some patients with asthma or COPD after 2 years of regular treatment. This might indicate that for certain groups of patients with mild asthma or COPD, periodic treatment schedules with inhaled steroids is the treatment policy for the future.(JAMA. 1995;274:161-164)

REFERENCES

1 +
Djukanovic R, Roche WR, Wilson JW, et al.  Mucosal inflammation in asthma. Am Rev Respir Dis . 1990;;142:434-457.
2 +
Thompson AB, Daughton D, Robbins RA, Ghafouri MA, Oehlerking M, Rennard SI.  Intraluminal airway inflammation in chronic bronchitis. Am Rev Respir Dis . 1989;;140:1527-1537.
3 +
Statement by the British Thoracic Society.  Guidelines for management of asthma in adults, I: chronic persistent asthma. BMJ . 1990;;301:651-653.
4 +
 International consensus report on diagnosis and treatment of asthma. Eur Respir J . 1992;;5:601-641.
5 +
Kerstjens HAM, Brand PLP, Hughes MD, et al, for the Dutch Chronic Non-specific Lung Disease Study Group.  A comparison of bronchodilator therapy with or without inhaled corticosteroid therapy for obstructive airways disease. N Engl J Med . 1992;;327:1413-1419.
6 +
Postma DS, Peters I, Steenhuis EJ, Sluiter HJ.  Moderately severe chronic airflow obstruction: can corticosteroids slow down obstruction? Eur Respir J . 1988;;1:22-26.
7 +
Juniper EF, Kline PA, Vanzieleghem MA, Ramsdale EH, O'Byrne PM, Hargreave FE.  Effect of long-term treatment with an inhaled corticosteroid (budesonide) on airway hyperresponsiveness and clinical asthma in nonsteroid-dependent asthmatics. Am Rev Respir Dis . 1990;;142:832-836.
8 +
Haahtela T, Järvinen M, Kava T, et al.  Comparison of a beta2-agonist, terbutaline, with an inhaled corticosteroid, budesonide, in newly detected asthma. N Engl J Med . 1991;;325:388-392.
9 +
Dompeling E, van Schayck CP, van Grunsven PM, et al.  Slowing the deterioration of asthma and COPD during bronchodilator therapy by adding inhaled corticosteroids. Ann Intern Med . 1993;;118: 770-778.
10 +
van Essen-Zandvliet EE, Hughes MD, Waalkens HJ, Duiverman EJ, Kerrebijn KF. Remission of childhood asthma after long-term treatment with an inhaled corticosteroid (budesonide). can it be reached? In: van Essen-Zandvliet EE. Long-term Intervention in Childhood Asthma. Rotterdam, the Netherlands: Erasmus University; 1993. Thesis.
11 +
Vathenen AS, Knox AJ, Wisniewski A, Tattersfield AE.  Time course of change in bronchial reactivity with inhaled corticosteroid in asthma. Am Rev Respir Dis . 1991;;143:1317-1321.
12 +
Jenkins CR, Woolcock AJ.  Effect of prednisone and beclomethasone dipropionate on airway responsiveness in asthma: a comparative study. Thorax . 1988;;43:378-384.
13 +
Bel EH, Timmers MC, Zwinderman AH, Dijkman JH, Sterk PJ.  The effect of inhaled corticosteroids on the maximal degree of airway narrowing to methacholine in asthmatic subjects. Am Rev Respir Dis . 1991;;143:109-113.
14 +
Kraan J, Koëter GH, van de Mark ThW, Sluiter HJ, Vries K de.  Changes in bronchial hyperreactivity induced by 4 weeks of treatment with antiasthmatic drugs in patients with allergic asthma: a comparison between budesonide and terbutaline. J Allergy Clin Immunol . 1985;;76:628-636.
15 +
Magnussen H, Willenbrock U, Jörres R.  Airway responsiveness, lung function and symptoms after cessation of high dose inhaled corticosteroids in patients with bronchial asthma. Am Rev Respir Dis . 1992;;145:A498.
16 +
Waalkens HJ, van Essen-Zandvliet EE, Hughes MD, et al.  Cessation of inhaled corticosteroid (budesonide) after long-term treatment in children with asthma results in rapid deterioration. Am Rev Respir Dis . 1993;;148:1252-1257.
17 +
Juniper EF, Kline PA, Vanzieleghem MA, Hargreave FE.  Reduction of budesonide after a year of increased use: a randomized controlled trial to evaluate whether improvements in airway responsiveness and clinical asthma are maintained. J Allergy Clin Immunol . 1991;;87:483-489.
18 +
Haahtela T, Järvinen M, Kava T, et al.  Effects of reducing or discontinuing inhaled budesonide in patients with mild asthma. N Engl J Med . 1994;; 331:700-705.
19 +
van den Broek PJJA, van Schayck CP, Dompeling E, Folgering H, van Weel C.  Is it possible to stop beclomethasone dipropionate after two years of treatment in asthma or COPD? Eur Respir J . 1993;;607:257s.
20 +
van Schayck CP, Dompeling E, van Herwaarden CLA, et al.  Bronchodilator treatment in moderate asthma or chronic bronchitis: continuous or on demand? a randomised controlled study. BMJ . 1991;; 303:1426-1431.
21 +
Taggart VS, Zuckerman AE, Lucas S, Acty-Lindsey A, Bellantini JA.  Adapting a self-management education program for use in an outpatient clinic. Ann Allergy . 1987;;58:173-178.
22 +
Silverman BA, Mayer D, Sabinsky R, et al.  Training perception of airflow obstruction in asthmatics. Ann Allergy . 1987;;59:350-354.
23 +
Charlton I, Charlton G, Broomsfield J, Mullee MA.  Evaluation of peakflow and symptoms only self management plans for control of asthma in general practice. BMJ . 1990;;301:1355-1359.
24 +
D'Souza W, Crane J, Burgess C, et al.  Community-based asthma care: trial of a 'credit card' asthma self-management plan. Eur Respir J . 1994;; 7:1260-1265.
25 +
Osman LM, Abdalla MI, Beattie JAG, et al.  Reducing hospital admission through computer supported education for asthma patients. BMJ . 1994;; 308:568-571.
26 +
Grampian Asthma Study of Integrated Care (GRASSIC). Effectiveness of routine self monitoring of peak flow in patients with asthma. BMJ . 1994;;308:564-567.
27 +
Whyte MK, Choudry NB.  Bronchial hyperresponsiveness in patients recovering from acute severe asthma. Respir Med . 1993;;87:29-35.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Djukanovic R, Roche WR, Wilson JW, et al.  Mucosal inflammation in asthma. Am Rev Respir Dis . 1990;;142:434-457.
2 +
Thompson AB, Daughton D, Robbins RA, Ghafouri MA, Oehlerking M, Rennard SI.  Intraluminal airway inflammation in chronic bronchitis. Am Rev Respir Dis . 1989;;140:1527-1537.
3 +
Statement by the British Thoracic Society.  Guidelines for management of asthma in adults, I: chronic persistent asthma. BMJ . 1990;;301:651-653.
4 +
 International consensus report on diagnosis and treatment of asthma. Eur Respir J . 1992;;5:601-641.
5 +
Kerstjens HAM, Brand PLP, Hughes MD, et al, for the Dutch Chronic Non-specific Lung Disease Study Group.  A comparison of bronchodilator therapy with or without inhaled corticosteroid therapy for obstructive airways disease. N Engl J Med . 1992;;327:1413-1419.
6 +
Postma DS, Peters I, Steenhuis EJ, Sluiter HJ.  Moderately severe chronic airflow obstruction: can corticosteroids slow down obstruction? Eur Respir J . 1988;;1:22-26.
7 +
Juniper EF, Kline PA, Vanzieleghem MA, Ramsdale EH, O'Byrne PM, Hargreave FE.  Effect of long-term treatment with an inhaled corticosteroid (budesonide) on airway hyperresponsiveness and clinical asthma in nonsteroid-dependent asthmatics. Am Rev Respir Dis . 1990;;142:832-836.
8 +
Haahtela T, Järvinen M, Kava T, et al.  Comparison of a beta2-agonist, terbutaline, with an inhaled corticosteroid, budesonide, in newly detected asthma. N Engl J Med . 1991;;325:388-392.
9 +
Dompeling E, van Schayck CP, van Grunsven PM, et al.  Slowing the deterioration of asthma and COPD during bronchodilator therapy by adding inhaled corticosteroids. Ann Intern Med . 1993;;118: 770-778.
10 +
van Essen-Zandvliet EE, Hughes MD, Waalkens HJ, Duiverman EJ, Kerrebijn KF. Remission of childhood asthma after long-term treatment with an inhaled corticosteroid (budesonide). can it be reached? In: van Essen-Zandvliet EE. Long-term Intervention in Childhood Asthma. Rotterdam, the Netherlands: Erasmus University; 1993. Thesis.
11 +
Vathenen AS, Knox AJ, Wisniewski A, Tattersfield AE.  Time course of change in bronchial reactivity with inhaled corticosteroid in asthma. Am Rev Respir Dis . 1991;;143:1317-1321.
12 +
Jenkins CR, Woolcock AJ.  Effect of prednisone and beclomethasone dipropionate on airway responsiveness in asthma: a comparative study. Thorax . 1988;;43:378-384.
13 +
Bel EH, Timmers MC, Zwinderman AH, Dijkman JH, Sterk PJ.  The effect of inhaled corticosteroids on the maximal degree of airway narrowing to methacholine in asthmatic subjects. Am Rev Respir Dis . 1991;;143:109-113.
14 +
Kraan J, Koëter GH, van de Mark ThW, Sluiter HJ, Vries K de.  Changes in bronchial hyperreactivity induced by 4 weeks of treatment with antiasthmatic drugs in patients with allergic asthma: a comparison between budesonide and terbutaline. J Allergy Clin Immunol . 1985;;76:628-636.
15 +
Magnussen H, Willenbrock U, Jörres R.  Airway responsiveness, lung function and symptoms after cessation of high dose inhaled corticosteroids in patients with bronchial asthma. Am Rev Respir Dis . 1992;;145:A498.
16 +
Waalkens HJ, van Essen-Zandvliet EE, Hughes MD, et al.  Cessation of inhaled corticosteroid (budesonide) after long-term treatment in children with asthma results in rapid deterioration. Am Rev Respir Dis . 1993;;148:1252-1257.
17 +
Juniper EF, Kline PA, Vanzieleghem MA, Hargreave FE.  Reduction of budesonide after a year of increased use: a randomized controlled trial to evaluate whether improvements in airway responsiveness and clinical asthma are maintained. J Allergy Clin Immunol . 1991;;87:483-489.
18 +
Haahtela T, Järvinen M, Kava T, et al.  Effects of reducing or discontinuing inhaled budesonide in patients with mild asthma. N Engl J Med . 1994;; 331:700-705.
19 +
van den Broek PJJA, van Schayck CP, Dompeling E, Folgering H, van Weel C.  Is it possible to stop beclomethasone dipropionate after two years of treatment in asthma or COPD? Eur Respir J . 1993;;607:257s.
20 +
van Schayck CP, Dompeling E, van Herwaarden CLA, et al.  Bronchodilator treatment in moderate asthma or chronic bronchitis: continuous or on demand? a randomised controlled study. BMJ . 1991;; 303:1426-1431.
21 +
Taggart VS, Zuckerman AE, Lucas S, Acty-Lindsey A, Bellantini JA.  Adapting a self-management education program for use in an outpatient clinic. Ann Allergy . 1987;;58:173-178.
22 +
Silverman BA, Mayer D, Sabinsky R, et al.  Training perception of airflow obstruction in asthmatics. Ann Allergy . 1987;;59:350-354.
23 +
Charlton I, Charlton G, Broomsfield J, Mullee MA.  Evaluation of peakflow and symptoms only self management plans for control of asthma in general practice. BMJ . 1990;;301:1355-1359.
24 +
D'Souza W, Crane J, Burgess C, et al.  Community-based asthma care: trial of a 'credit card' asthma self-management plan. Eur Respir J . 1994;; 7:1260-1265.
25 +
Osman LM, Abdalla MI, Beattie JAG, et al.  Reducing hospital admission through computer supported education for asthma patients. BMJ . 1994;; 308:568-571.
26 +
Grampian Asthma Study of Integrated Care (GRASSIC). Effectiveness of routine self monitoring of peak flow in patients with asthma. BMJ . 1994;;308:564-567.
27 +
Whyte MK, Choudry NB.  Bronchial hyperresponsiveness in patients recovering from acute severe asthma. Respir Med . 1993;;87:29-35.

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