Abstract

Background. The benefit of a temporary increase in inhaled corticosteroid dose when asthma control is worsening has not been confirmed. 

Aims: To determine the benefit of a self-management plan, including a four-fold increase in inhaled corticosteroid dose, when asthma control starts to deteriorate. The primary outcome was time to first severe asthma exacerbation - defined as treatment with at least 3 days or oral corticosteroids or an unscheduled health care visit.

Methods: Multicentre, parallel group, randomised, open label trial in adults patients with a clinical diagnosis of asthma currently treated with inhaled corticosteroids +/- other controllers and at least one exacerbation requiring oral corticosteroids in the previous year. Participants were randomised to one of two self-management plans for a year. The self-management plans were identical except at zone 2. Here both groups were advised to increase bronchodilator medication whilst the modified group also quadrupled their inhaled corticosteroid dose.

Results: Baseline characteristics of the 1922 randomised participants were well matched (mean age, 56 years; 70% using a ICS/LABA combination inhaler).  Severe asthma exacerbation rate  was 0.79 v 0.65 (per person year) in the usual care and modified care groups respectively with an adjusted hazard ratio of 0.81 (95% CI 0.71 to 0.92, p=0.002). The results were similar in patients using low and high dose inhaled corticosteroids as maintenance treatment.

Conclusion: A self-management plan, which includes a temporary four-fold increase in inhaled corticosteroid dose, reduces severe asthma exacerbations.