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• W4245896260 abstract "A few thousand patients die of asthma each year in the United States, and Dr. Sears fears that an explanation may be found in his discovery that some patients with relatively mild asthma appear to suffer deterioration when they use β-adrenergic aerosols routinely. Nevertheless, it is evident that many millions of patients use routine β-adrenergic aerosol therapy, and there is good reason to believe that as a result they enjoy a comfortable life. I feel that there is a logical inconsistency in the extension of Sears's claims: he implies that patients with chronic, variable asthma are harmed by using standard daily doses of β-adrenergic therapy, but their resultant lapse into acute asthma can be safely managed by giving far greater doses of these same drugs. It is possible that the apparent harm of routine therapy is only of significance in a subgroup of patients such as those who use fenoterol. The established dogma of using routine β-agonist aerosol therapy is supported by the bulk of the literature and by a vast experience.1Britton M. Salmeterol and salbutamol: large multicentre studies.Eur Respir Rev. 1991; 1: 288-292Google Scholar, 2Kesten S Chapman KR Broder I Cartier A Hyland RH Knight A et al.A three-month comparison of twice daily inhaled formoterol versus four times daily inhaled albuterol in the management of stable asthma.Am Rev Respir Dis. 1991; 144: 622-625Crossref PubMed Google Scholar, 3Peel ET Gibson CJ. Effects of long-term inhaled salbutamol therapy on the provocation of asthma by histamine.Am Rev Respir Dis. 1980; 121: 973-978PubMed Google Scholar, 4Shepherd GL Jenkins WJ Alexander J. Asthma exacerbations in patients taking regular salmeterol or salbutamol for symptoms [letter].Lancet. 1991; 337: 1424Abstract PubMed Scopus (11) Google Scholar, 5Wilson AF. Cardiovascular effects: β2 agonists.J Asthma. 1990; 27: 111-116Crossref PubMed Scopus (3) Google Scholar Before aerosol steroids were introduced in the 1960s, children with asthma relied principally upon sympathomimetic aerosols. With few exceptions, it appears that these children not only did well, but they “grew out” of their asthma. In the era of aerosol steroids, there is still enough documented experience to suggest that long-term β-agonist aerosol therapy given alone is beneficial in children and younger adults.6Committee on Safety of MedicationsBeta-agonist use in asthma: report from the CSM Working Party.Curr Probl. 1992; 32: 1-2Google Scholar, 7Lofdahl CG Svedmyr N. Beta-agonists: still more friends than foes.Eur Respir J. 1992; 5: 898-900Google Scholar, 8Nelson HS. Adrenergics in asthma: where we stand today.J Respir Dis. 1986; 7: 43-49Google Scholar The vision of deaths that Dr. Sears relates to the continuing daily use of β-agonists appears to be a mirage; most deaths occur in poorly compliant, psychologically disturbed, or economically disadvantaged patients with brittle asthma who fail to use their medications appropriately.9Boulet LP Deschesnes F Turcotte H Gignac F. Near-fatal asthma: clinical and physiologic features, perception of bronchoconstriction, and physiologic profile.J Allergy Clin Immunol. 1991; 88: 838-846Abstract Full Text PDF PubMed Scopus (96) Google Scholar,10Patterson R Greenberger PA. Problem cases in asthma and problems in asthma management.Chest. 1992; 101: 430S-431SAbstract Full Text Full Text PDF PubMed Google Scholar Fortunately, there is an important point that both sides can agree upon: without doubt, all drugs can be dangerous if used in excess. Thus, if a patient uses “excessive” doses of a β-adrenergic aerosol, there is a risk of an adverse outcome. The critical issue lies in the definition of “excessive”; all parties might agree that this means “more than is symptomatically necessary.” Two problems face us, however: (1) Do all symptoms (eg, wheezing on forced exhalation as well as wheezing on effort) deserve treatment? (2) How should we interpret the term “p.r.n.”? If I hear an asthmatic wheeze, but he does not report dyspnea on effort (perhaps because he makes no effort), I tend to advise treatment with β-adrenergic aerosol several times a day. Dr. Sears presumably would tend not to treat such a patient, unless the individual started exercising and became aware of dyspnea. Thus, Dr. Sears advocates β-adrenergic aerosols only for airway obstruction that becomes symptomatic under special circumstances, whereas I favor treatment for all patients who present any evidence of reversible asthmatic bronchoconstriction. The division between the Sears camp and traditionalists such as myself may depend on inappropriately loose terminology; and our differences may be partially resolved if we could correlate the need to treat clinical disease with the presence, as Sears11Sears MR. Dose reduction of beta-agonists in asthma.Lancet. 1991; 338: 1331-1332Abstract PubMed Scopus (23) Google Scholar suggests, of objective quantified measures of disordered physiology. If we could establish a rational set of criteria for defining “p.r.n.,” we might find that our different approaches are really very similar. Thus, it is probable that those asthmatic patients for whom 1 choose to not prescribe routine β-agonists are similar to those of Dr. Sears, whereas those for whom he does end up having to treat with routine daily “p.r.n.” β-agonist therapy are similar to those whom I treat with two- to four-times-a-day therapy. There is an intermediate group for whom the establishment of an appropriate therapeutic regimen is a challenge for each of us. However, it is now important for the two apparently opposed views on asthma therapy to define a mutually acceptable approach to β-agonist dosing that covers the majority of patients with asthma—leaving room for disagreement on the remaining few. β-Agonists and Bronchial AsthmaCHESTVol. 104Issue 2PreviewIn an article that appeared in the June 1992 issue of Chest, Dr. Ziment1 questions whether asthma deaths are due to overtreatment or undertreatment, and refers to studies that I and colleagues have undertaken over the last 10 years with respect to asthma morbidity and mortality.2,3 Dr. Ziment states that it is “curious” that I now believe that there are risks attached to the use of β-agonist therapy, whereas I previously stated that there was no evidence for direct toxicity of high-dose β-agonist therapy. Full-Text PDF" @default.
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