Quadrupling Inhaled Gluococorticoid Dose To Abort Asthma Exacerbations

Background Asthma exacerbations are frightening for patients and are occasionally fatal. We tested the concept that a self-management plan, which included a temporary quadrupling of the dose of inhaled glucocorticoid when asthma control started to deteriorate, would reduce severe asthma exacerbations in adults with asthma. Methods A pragmatic, unmasked, randomized trial in adults with asthma, treated with inhaled glucocorticoids with or without additional add-on therapy and one or more exacerbation in the previous 12 months. We compared a self-management plan that included a four-fold increase in inhaled glucocorticoid dose with the same plan without an increase in glucocorticoid, over 12 months. The primary outcome was time to first severe asthma exacerbation, defined as treatment with systemic glucocorticoids or unscheduled healthcare consultation for asthma. Results 1922 participants were randomized of whom 1871 contributed to the primary analysis. The number of participants having a severe asthma exacerbation in the year after randomization was 484 (51.6%) in the non-quadrupling group and 420 (45.0%) in the quadrupling group, with an adjusted hazard ratio for time to first severe exacerbation of 0.81 (95% confidence interval 0.71 to 0.92, p-value 0.002). Adverse effects, primarily related to local effects of inhaled glucocorticoids, were increased in the quadrupling group. Conclusion Severe exacerbations of asthma were reduced in adults with asthma with a personalized self-management plan that included a temporary four-fold increase in inhaled glucocorticoid dose when asthma control started to deteriorate.