Inhaled versus oral steroids for adults with chronic asthma

 

Abstract

Background

Steroids are a common treatment of chronic asthma as a maintenance therapy in both developed and developing countries across the world. The cost of inhaled steroids means that in developing countries their availability is limited, leading to poorly controlled asthma in patients who are prescribed low dosage inhaled steroids, or the additional use of oral steroids to control patients' asthma.

This review seeks to determine what dosage of oral steroids equates to the therapeutic effects of a moderate to high doses of inhaled steroids.

Objectives

To determine therapeutically equivalent doses of inhaled versus oral steroids for adults with chronic asthma.

Search methods

The Cochrane Airways Group trials register was searched and experts in the field were contacted. Searches were current as of August 2008.

Selection criteria

Randomised controlled trials were selected of at least 4 weeks duration and included patients over the age of 15 years with chronic asthma. Trials compared inhaled steroids and oral prednisolone or prednisone; where the maximum dose for inhaled steroids was 2000 mcg/day and prednisolone 60 mg (on alternate days).

Data collection and analysis

Two independent reviewers screened 1285 titles and abstracts from the electronic search, bibliography searches and other contacts. Of these, 10 trials met previously defined inclusion criteria. Two reviewers independently extracted study characteristics, and outcome measures.

Main results

All trials were small and no data could be pooled. Carry-over effects were present in at least one cross-over trial. Data from six trials produced the same pattern, in which prednisolone 7.5-12 mg/day appeared to be as effective as inhaled steroid 300-2000 mcg/day. In two trials, inhaled steroid 300-400 mcg/day was more effective than prednisolone 5 mg/day. All doses of inhaled steroid appeared to be more effective than alternate day doses of prednisolone up to 60 mg on alternate days. Side-effect data were reported too variably to permit comparisons. A 30% incidence was reported in one study in patients receiving prednisolone 5 mg/day, none were reported in patients on inhaled steroids.

Authors' conclusions

A daily dose of prednisolone 7.5-10 mg/day appears to be equivalent to moderate-high dose inhaled corticosteroids. Side-effects may be present on low doses, so if there is no alternative to oral steroids, the lowest effective dose should be prescribed.

 

Plain language summary

Inhaled versus oral steroids for adults with chronic asthma

Inhaled corticosteroids form the first choice for preventative treatment of asthma, but they remain expensive for health economies in developing countries. Oral prednisolone is very much cheaper. In this review, we found that, in the management of adults with chronic asthma, a daily dose of prednisolone 7.5 mg/day appears to be equivalent to a moderate to high dose of inhaled steroids (300-2000 mcg/day). Side effects may be present even with low doses of prednisolone, so if there is no alternative to oral steroids, the lowest effective dose should be prescribed. These findings may be use in developing countries where inhaled steroids are not widely available.

 

摘要

背景

成人慢性氣喘病以吸入與口服類固醇治療之比較

類固醇在世界各地的已開發國家和發展中國家常被當成維持療法來治療慢性氣喘病。吸入性類固醇的價錢,意味著它們在發展中國家取得不易，導致以低劑量吸入式類固醇控制氣喘的病患,其氣喘病控制不良，或需要補充口服類固醇來控制氣喘病。本文獻回顧的目的，是為了要決定多少口服類固醇劑量,可達到相當於中到高劑量吸入性類固醇之療效。

目標

類固醇在世界各地的已開發國家和發展中國家常被當成維持療法來治療慢性氣喘病。吸入性類固醇的價錢,意味著它們在發展中國家取得不易，導致以低劑量吸入式類固醇控制氣喘的病患,其氣喘病控制不良，或需要補充口服類固醇來控制氣喘病。本文獻回顧的目的，是為了要決定多少口服類固醇劑量,可達到相當於中到高劑量吸入性類固醇之療效。

搜尋策略

我們搜尋了Cochrane Airways Group 臨床試驗登錄資料庫,並連繫該領域的專家。目前搜尋至2006年8月。

選擇標準

我們選擇至少四星期以上並且包括年齡超過15歲的慢性氣喘病人的隨機對照試驗。試驗以吸入式類固醇來比較口服去氫可體醇錠(prednisolone)或強體松(prednisone);吸入性類固醇的最高劑量是每天2000微克(mcg),口服去氫可體醇錠的最高劑量是60毫克(mg)(隔天使用)。

資料收集與分析

兩個獨立審查員從電子搜尋,參考書目搜尋和接觸其他的來源,篩選了1285個標題和摘要。其中10個試驗符合了之前定義的納入標準。二個審查員獨立地萃取了研究特徵和結果測量值。

主要結論

所有的試驗都很小，並且數據不可能合併。我們在至少一個的交叉試驗(crossover effects)裡有發現殘餘效應(carryover effect)。六個試驗的數據產生同樣的模式，每天7.5 – 12毫克的口服去氫可體醇似乎跟每天300 – 2000微克的吸入性類固醇一樣有效。在二個試驗中，每天300 – 400微克的吸入式類固醇比每天5毫克的口服去氫可體醇有效。所有劑量的吸入性類固醇似乎比隔天使用的60毫克的口服去氫可體醇來的有效。副作用的數據變化太大所以很難比較。在一個病人每天接受5毫克口服去氫可體醇的研究中,30%的病人產生副作用。使用吸入性類固醇的病人中,則沒有副作用被通報。

作者結論

口服去氫可體醇每日劑量7.5 – 10毫克看來是與中到高劑量的吸入式類皮質激素有同樣的效果。就算在使用低劑量的時候,都可能有副作用，因此，除了口服類固醇之外沒有其他選擇時，應該給予病人最低的有效劑量。

翻譯人

本摘要由臺北醫學大學萬芳醫院楊璧如翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

當病人無法負擔吸入性類固醇來治療氣喘病的時候,可以用每天一劑比較便宜的類固醇口服去氫可體醇來緩解氣喘症狀。吸入性皮質類固醇是預防氣喘病之首選,然而就發展中國家的健康經濟(health economies)而言,它們還是昂貴的。相較之,口服去氫可體醇則非常便宜。我們在這個回顧中發現，每日劑量7.5毫克的口服去氫可體醇相當於中到高劑量的吸入性類固醇(每天300 – 2000微克)。就算是低劑量的口服去氫可體醇,也可能有副作用。因此，如果沒有除了口服類固醇的其他選擇，醫生應該給予病人最低的有效劑量。這些研究結果,可以提供給那些吸入性類固醇還無法被廣泛使用的發展中國家使用。