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Are Inhaled Steroids the Best Treatment for Mild Asthma?

A new study sheds some doubt on the question of whether inhaled steroids are the best treatment approach for those who have mild, persistent asthma.1

Mild asthma is different

First, let’s talk about a significant way that the mild forms of asthma differ from the more severe forms, which are harder to control. Certain white blood cells in the lung are part of the body’s immune system and are called eosinophils. These eosinophils are biomarkers of inflammation in the lung.1

Past studies have shown that many people with mild persistent asthma had very low levels of these inflammatory cells. In contrast, people with severe asthma tend to have very high levels of these same cells. Studies have also shown that people with low eosinophils do not respond as well to steroid treatment.

But information on eosinophils in people with mild asthma has been somewhat lacking. Measuring levels of these biomarkers is complex and generally used only in cases of severe asthma.

Although considered the “gold standard” of asthma treatment, inhaled steroids are expensive and can also sometimes have unwanted side effects. So, researchers decided to take a closer look at people with mild asthma. Their goal was to see if there might be other treatment methods that would work just as well in controlling symptoms.1

Details of the study

The study was funded by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health (NIH). It was published recently in the New England Journal of Medicine (NEJM). In addition, it was presented at the international conference of the American Thoracic Society in May of this year.

Here are a few facts about the study:1

  • Included 295 people over the age of 12 with mild persistent asthma
  • Group was divided into two groups, either high eosinophils or low eosinophils
  • Participants were assigned in random sequence to each of three treatment groups for 12-week periods: inhaled steroids; long-acting muscarinic antagonists (LAMA), a nonsteroidal treatment for uncontrolled asthma; or placebo
  • By the end of the study, each participant had rotated through all 3 different treatment methods

Study results

Past studies suggested that about half of people with mild, persistent asthma have low eosinophil levels. But, in this study, 73% of the participants had low levels. This was much higher than expected.

Those who were “eos-low” did not respond any better to inhaled steroids than to placebo. However, the small number who were “eos-high” did respond much more positively to inhaled steroids.

62% of the “eos-low” group responded better to the LAMA treatment than they did to placebo. Although this was a relatively low number, it still suggests that LAMA medicines may be a better choice for mild asthmatics than steroids.

During the course of the study, there were no significant differences in asthma attacks or treatment failures between any of the groups.

Conclusions

The study authors and other reviewers emphasize that this study was too small a sample size to spur widespread changes in treatment for those with mild, persistent asthma. Although the results are intriguing, there is not enough evidence yet to stop prescribing steroids as the standard. However, the study does add to the overall body of evidence in that direction.

In addition, experts say that these results do indicate a need for larger, more definitive studies in this direction. But for now, people with asthma should continue to follow their doctor’s current treatment plan. It could be that we mild asthmatics will see changes in the future, though. I know I’d love to give up my expensive inhaled steroid!

What are your thoughts? Please share in the comments below!

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Asthma.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

  1. Large portion of patients with mild persistent asthma and low sputum eosinophils respond equally well to inhaled corticosteroids as placebo. May 19, 2019. https://www.nhlbi.nih.gov/news/2019/large-portion-patients-mild-persistent-asthma-and-low-sputum-eosinophils-respond-equally
  2. Nackerdien, Z. Non-Eosinophilic Mild Asthma May Not Benefit From Mometasone, Tiotropium. May 31, 2019. Accessed online at https://www.medpagetoday.org/allergyimmunology/asthma/80165?vpass=1

Comments

  • TracyLee
    1 week ago

    Kathi, when I read of this study in a newsletter, I decided to run my own trial. The asthma I developed as a mature adult 5 years ago is rated as mild based on 2 spirometry tests and that I report rarely using my rescue inhaler.

    I used montelukast + ICS a full month before the first test and I rarely use my rescue inhaler because I use a P100 respirator whenever I am near triggers (outside when the ozone is at “30” on the AQI “Good” level, “20” AQI for PM2.5, and if I am within 5 feet of anyone who smells of artificial fragrance (even men because of dry sheet fragrance popularity — pretty much everybody everywhere except my spouse and a neighbor who has since moved), and dogs.

    I haven’t had a challenge test. The pulmonologist has not seen me when a trigger causes a “coughing fit” with buckets of mucus, because thankfully albuterol does a great job.

    Although it was obvious the montelukast was a big help when I tried going without it for 5 days this past winter, because of my needing the mask even while taking the highest dose recommended 3 different kinds of ICS, I’ve never been sure that the ICS made a difference. (I ended up stuck in the P100 to work full time for my last two years in order to control the heavy mucus cough.)

    I have excellent control of triggers at home so since retirement (yay!), I went back down to a medium dose of ICS. Unfortunately, leaving a workplace with multiple triggers did not reduce my sensitivity. I still have to use the P100 OR use the albuterol for the grocery store, family gatherings, or to walk out the door to the mailbox when the air is described as above. Travel involving overnight stays is impossible because I cannot convince myself that I can sleep in the bulky cumbersome mask, and I can’t sleep on the albuterol. (The N95 masks don’t have the gas cartridges to filter odors.)

    So when I ready about this study, I looked up my record for the one IgE test. I scored as “normal”. I called the pulmonologist and told him I wanted to postpone my biannual appointment to see what would happen if I reduced the ICS “medium” dose (Qvar 80mcg 2x a day) to “low” (40 mcg 2x a day). I didn’t want to stop the ICS completely, in case it has been making a difference.

    My plan was to do 3 weeks of 2x 40 mcg, measuring my peak flow first thing in the morning because this is when I always have a slight mucus cough. Then I would do 3 weeks of 80 mcg, measuring at the same time of day.

    I have now completed the 3 weeks of 40 mcg. Although there have been slight daily fluctuations, when I average each week, the peak flow averages for week 3 is no worse than the average for week 1 and 2.

    Today, I started back on the 2x 80mcg, the medium dose. In 3 weeks, I hope to be able to draw a conclusion and share it with my pulmonologist.

  • Kathi MacNaughton author
    1 week ago

    TracyLee… Thanks so much for sharing your experience! I was glad, though, to read that you did inform your pulmonologist first. Your results are quite interesting, and I look forward to hearing what happens next.

    Sorry to hear about your extreme sensitivity. It must be tough having to wear the mask so much.

    Take care,
    Kathi

  • Shellzoo
    3 weeks ago

    That is very interesting. I know my eosinophil count was normal the last time I had a complete blood count done but that was prior to being diagnosed with asthma. I was diagnosed based on spirometry and FeNO scores. I responded very well to inhaled steroids and my FeNO test was much better on my next visit. I do think it would be wonderful to have better targeted treatments based on asthma types in the future. Nice article!

  • Kathi MacNaughton author
    3 weeks ago

    Thanks, Shellzoo. I found the study interesting as well. But glad that you responded so well to the inhaled steroids too!

    Best, Kathi

  • Shellzoo
    3 weeks ago

    Yeah, I responded well but still ended up on Spiriva too. There is so much to learn about asthma but I am glad there is research and education.

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