Corticosteroids in Treatment of Chronic Asthma

Abstract

An account is given of the results of treatment with prednisolone, and of the side-effects encountered, in 273 patients with chronic asthma (245 adults and 28 children) in whom treatment had been maintained for periods of 1 to 10 years. In 180 (74%) of the 245 adult patients prednisolone was given intermittently (20 mg./day on three consecutive days per week, 17.5 mg./day on two consecutive days in every four, or 17.5 mg. on alternate days) ; the remainder received continuous (daily) treatment with an average dose of 10.1 mg./day. In 212 patients the response to prednisolone was tested by serial estimations of forced expiratory volume (1 second) before they were accepted for long-term treatment, and the length of remission after withdrawal of prednisolone was used to determine the appropriate regimen in each case. In the remaining 33 patients, who started corticosteroid therapy prior to 1958, no such preliminary assessment was undertaken, and they were all given continuous (daily) treatment. The symptoms of asthma were almost completely relieved in two-thirds of those patients who were found suitable for treatment on three consecutive days per week or on two consecutive days in four, but in only one-third of those who required treatment on alternate days or every day. Those who received daily treatment without preliminary assessment showed a response midway between that observed in the first two categories. In the series as a whole 81% of patients obtained a useful degree of symptomatic improvement, and in only 5% was treatment totally ineffective. The maintenance dose of prednisolone was reduced, often considerably, in about 50% of cases, but it was possible to withdraw treatment completely in only 5%. The frequency of side-effects, such as marked hypercorticism, peripheral oedema, and spontaneous fracture, was lower in patients on regimens of intermittent treatment than in those receiving prednisolone daily. This may have been partly related to the slightly smaller mean annual dose of prednisolone received by patients on intermittent treatment, but significantly fewer incidents of spontaneous fracture occurred with intermittent treatment than with continuous (daily) treatment given in a comparable mean annual dose. The incidence of suspected and proved peptic ulceration was approximately the same in the two treatment groups. Sixteen patients (6%) died, seven from status asthmaticus and nine from other causes. The deaths from status asthmaticus were probably due to failure to increase the dose of corticosteroid when acute symptoms supervened. The death rate was no higher in patients on intermittent treatment regimens than in those given corticosteroids every day. The results in 28 children were similar to those obtained in the 245 adults, but the children required a proportionately higher dose of corticosteroid, and were in consequence more liable to develop the stigmata of hypercorticism. More serious side-effects were uncommon, and no deaths were recorded. Intermittent treatment was effective less often in children than in adults, but complete withdrawal of corticosteroids was achieved more often in children (18%) than in adults (5%). Although growth had already been retarded in many children with severe chronic asthma before corticosteroids were given, it is possible that the administration of these agents was responsible for further retardation of growth in a few cases. This investigation has shown that in suitably selected cases regimens of intermittent treatment with prednisolone are as effective in controlling the symptoms of chronic asthma as continuous (daily) treatment. There are some indications that side-effects are less likely to be produced by intermittent than by continuous administration of prednisolone, but further studies will be required to confirm this tentative conclusion. © 1966, British Medical Journal Publishing Group. All rights reserved.