Intranasal corticosteroids for asthma control in people with coexisting asthma and rhinitis

 

Abstract

Background

Allergic rhinitis and asthma are mediated by similar allergic mechanisms. They may represent two manifestations of the same united airway disease and therefore intranasal corticosteroids (INCS) could improve asthma. Nevertheless none of the asthma guidelines have advocated intranasal corticosteroids for asthma.

Objectives

To assess the efficacy of intranasal corticosteroids on asthma outcomes in people with rhinitis and asthma.

Search methods

We searched the Cochrane Airways Group trials register, the Cochrane Central Register of Controlled Trials (Issue 1, 2003), MEDLINE and reference lists of articles. We also contacted researchers in the field. The last search was conducted in March 2004.

Selection criteria

Randomised controlled trials comparing intranasal corticosteroids to intranasal placebo or to other traditional asthma treatments were included. Intrabronchial corticosteroids were not allowed but a device combining intranasal and intrabronchial corticosteroid was considered as being a primary INCS technique and was therefore also compared to placebo.

Data collection and analysis

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Quality assessment for the 14 eligible studies was performed using the Jadad score and by ranking allocation concealment. Statistical analysis for continuous data was done by weighted mean difference or standardised mean difference.

Main results

Fourteen trials involving 477 people were included. Meta-analysis for asthma outcomes failed to show a statistically significant benefit of INCS in asthma. However, for symptom scores and forced expiratory volume in one second, the trend favoured a beneficial effect of INCS. For asthma symptom scores (two parallel studies), the standardised mean difference was 0.61 (95% confidence interval (CI) -0.04 to 1.26). Meta-analysis for forced expiratory volume in one second (five parallel studies) gave a standardised mean difference of 0.31 (95% CI -0.04 to 0.65). In the parallel studies, meta-analysis of peak expiratory flow gave a standardised mean difference of -0.10 Litres/min (95% CI -0.55 to 0.35) for mean peak flow (three studies). Meta-analysis for methacholine airway responsiveness (three parallel studies) showed a standardised mean difference of -0.20 (-95% CI 0.64 to 0.24).

Authors' conclusions

Intranasal corticosteroids were well tolerated. While INCS tended to improve asthma symptoms and forced expiratory volume in one second, the results did not reach significance. The combination of intranasal plus intrabronchial corticosteroids should remain the current clinical practice until more research is done.

 

Plain language summary

Intranasal corticosteroids for asthma control in people with coexisting asthma and rhinitis

It has been suggested for nearly twenty years that nasal sprays containing corticosteroids might improve asthma outcomes in people suffering from both asthma and rhinitis. Intranasal corticosteroids had few side effects in people with mild asthma, but the improvements in symptoms scores and lung function could have arisen by chance. Intranasal corticosteroids may be a promising alternative treatment for patients with rhinitis and mild asthma. More research is needed before considering changing the current practice of prescribing corticosteroids delivered by oral inhalers for asthma, and by nasal sprays for rhinitis.

 

摘要

背景

合併氣喘及鼻炎患者以鼻內皮質類固醇控制氣喘

過敏性鼻炎及氣喘均是由相似的過敏機制所調控。這兩種疾病也許代表著同一種氣道疾病的兩種表現，因此，鼻內類固醇(INCS)可改善氣喘。然而，目前沒有氣喘的指引建議使用鼻內類固醇來治療氣喘。

目標

評估合併氣喘及鼻炎患者使用鼻內類固醇對氣喘的效果。

搜尋策略

我們搜尋Cochrane Airways Group trial Register，Cochrane Central Register of Controlled Trials(2003年第1期)，MEDLINE及相關文章的參考文獻。我們亦聯絡此一領域的研究人員，最後的搜尋是在2004年3月。

選擇標準

納入比較鼻內皮質類固醇及鼻內安慰劑或其他傳統氣喘治療的隨機對照試驗。使用支氣管內皮質類固醇的患者將予排除，但合併鼻內及支氣管內皮質累固醇的用藥裝置被視為基於INCS技術的設計，故亦與安慰劑比較。

資料收集與分析

二位審查者獨立地評估試驗品質及摘錄數據，並聯絡研究的作者索取額外的資料。對14個被選出來的研究以Jadad評分及排序分布隱匿來分析品質。連續數據以權重平均差或標準化平均差作統計分析。

主要結論

包含477名受試者的14個研究被納入分析。氣喘治療結果的綜合分析並未呈現INCS對氣喘有統計學上有意義的效益。然而，在症狀評分及一秒用力呼氣容積均顯示INCS傾向具有療效。氣喘症狀評分(兩項平行研究)的標準化平均差為0.61 (95%信賴區間[CI]−0.04至1.26)。一秒用力呼氣的綜合分析(五項平行研究)所得的標準化平均差為0.31(95% CI −0.04至0.65)。在平行研究中，頂?呼氣率的綜合分析(三項研究)對平均頂?流量可得的標準化平均差為−0.10 L/min(95% CI −0.55至0.35)。以methacholine氣道反應的綜合分析(三項平行試驗)所呈現的標準化平均差為−0.20(−95% CI 0.64至0.24)。

作者結論

鼻內皮質類固醇之耐受性良好。INCS有改善氣喘症狀及一秒用力呼氣容積的趨勢，但未達統計學意義。再有更多研究完成之前，合併鼻內及支氣管內皮質類固醇仍應是目前臨床處置的方式。

翻譯人

本摘要由中國醫藥大學附設醫院陳祖裕翻譯。

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

總結

皮質類固醇鼻噴劑或能改善合併氣喘及慢性鼻塞或流鼻水的患者之氣喘狀況，但需有更多的研究。含皮質類固醇的鼻噴劑可改善合併氣喘及鼻炎的患者的氣喘狀況已被提出近20年。鼻內皮質類固醇對輕度氣喘患者的副作用很少，但症狀評分及肺功能的改善卻是偶而出現。鼻內皮質類固醇可能是合併鼻炎及輕度氣喘患者另一種有效的治療。在考慮改變目前以口腔吸入器吸入皮質類固醇治療氣喘及鼻噴劑治療鼻炎的治療方式之前，需有更多的研究。