CORTICOSTEROIDS DAILY OR AS NEEDED FOR ASTHMA?
They may be equally effective.
A recent study reports that the use of corticosteroids according to necessity only may be as effective as a daily regimen in controlling mild persistent asthma.
Although daily antiinflammatory therapy to control such asthma is recommended in the treatment guidelines set forth by the National Heart, Lung, and Blood Institute, the American Academy of Asthma, Allergy, and Immunology, and the American Lung Association, many patients may be using asthma medications only when symptoms worsen, as is suggested by an analysis of pharmacy records indicating that most patients don't fill their maintenance asthma medication prescriptions (for inhaled corticosteroids or leukotriene receptor antagonists) on schedule, perhaps because mild or intermittent symptoms cause them to feel that there is no need for daily use.
Two hundred and twenty-five adults were enrolled in a double-blind trial and randomly assigned to one of three treatment plans-an intermittent-treatment plan (inhaled albuterol as needed, plus budesonide or prednisone as symptoms worsened), the intermittent-treatment plan combined with daily treatment with the inhaled corticosteroid budesonide, or the intermittent treatment plan combined with daily treatment with the leukotriene receptor antagonist zafirlukast. Patients who smoked, those who had respiratory tract infections, those who had used corticosteroids within the preceding six weeks, those who had been hospitalized for asthma, or those who had paid two or more visits to the ED because of asthma within the preceding year were excluded. The primary outcome was peak expiratory flow (PEF) in the morning, and forced expiratory volume in one second (FEV1) before and after bronchodilator treatment, the frequency of exacerbations, the degree of asthma control, the number of days without symptoms, and the quality of life served as other outcomes.
There were no clinically significant differences among the three treatment groups with respect to morning PEF or the frequency of exacerbations of asthma. But among patients in the group receiving daily budesonide there were 1.2 more days free of symptoms during a two-week period (representing 26 more symptom-free days, annually), as well as greater improvements in lung function and airway biology (pre-bronchodilator FEV1, bronchial reactivity, the percentage of eosinophils in sputum, exhaled nitric oxide levels, and asthma control scores), compared with those in the other two groups.
Additional studies are warranted to determine whether the use of inhaled corticosteroids as needed or of oral corticosteroids in short, intermittent courses, each a novel approach to the treatment of mild persistent asthma, is recommended.
Boushey Homer A, et al. N Engl J Med 2005;352(15):1519-28.
AMIODARONE VS. SOTALOL FOR ATRIAL FIBRILLATION
Sotalol appears to be superior.
A Department of Veterans Affairs cooperative study reports that, when used in patients who do not have ischemic heart disease, amiodarone is far superior to sotalol in the maintenance of sinus rhythm.
In the double-blind, placebo-controlled trial, 665 patients were randomly assigned to receive amiodarone (n = 267), sotalol (n = 261), or a placebo (n = 137). To qualify, subjects had to be taking anticoagulant therapy and had to have had persistent, documented atrial fibrillation (AF) for at least the immediately preceding 72 hours and at randomization; patients with atrial flutter or paroxysmal AF were excluded.
Baseline evaluations included chest radiographs, 12-lead electrocardiograms, complete blood counts, urinalyses, thyroid function tests, hepatic function panels, serum chemistry panels, and serum digoxin levels; patients were monitored for one to four and a half years, the primary end point being the interval (after the 28th day) to recurrence of AF after sinus rhythm had been restored, as determined by weekly "transtelephonic" electrocardiographic monitoring. In patients in whom cardioversion didn't spontaneously occur by the 28th day, direct-current (DC) cardioversion was performed. If patients converted but experienced a recurrence of AF after 28 days, DC cardioversion was again attempted. (Those who hadn't responded to DC conversion by day 28 were withdrawn from the study, taken off medication or placebo, and monitored for one year.)
Spontaneous cardioversion occurred in 27.1% of patients in the amiodarone group, 24.2% of those in the sotalol group, and 0.8% of those in the placebo group. Although the spontaneous cardioversion percentages were comparable in the amiodarone and sotalol groups, the median interval before the recurrence of AF was widely and remarkably discrepant between them-487 days in the amiodarone group and 74 days in the sotalol group (the median interval was six days in the placebo group). (In a subgroup of patients who had ischemic heart disease, the median intervals before recurrence of AF were longer, at 569 days in the amiodarone group and 428 days in the sotalol group, a difference not statistically significant.) With the restoration and long-term maintenance of sinus rhythm, quality of life scores and the capacity for exercise among the study participants were significantly improved.
The researchers conclude that, although amiodarone and sotalol appear to be equally effective in restoring sinus rhythm in the presence of AF, amiodarone was far superior in maintaining it in patients without ischemic heart disease.
Singh BN, et al. N Engl J Med 2005;352 (18):1861-72.