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In this systematic review and meta-analysis, investigators conducted a standardized comparison of the effectiveness and safety of various drug maintenance strategies for preventing asthma exacerbations. They evaluated 66 trials (60,000 patient-years of follow-up) in which results of 15 strategies (monotherapy with short- or long-acting β-agonists, leukotriene-receptor antagonists, or low- or high-dose inhaled corticosteroids [ICSs]; or various combination therapies) were reported. Participants were adults with asthma who were randomized to maintenance treatment of at least 24 weeks' duration.
Low-dose ICSs were superior to placebo and all other single-agent strategies for preventing severe exacerbations (i.e., prescription for systemic corticosteroids for ≥3 days, emergency department visit, or hospitalization). Only combinations of ICSs plus long-acting β-agonists lowered risk for severe exacerbations significantly better than low-dose ICS monotherapy (by about 50%). All other strategies that combined ICSs and other agents were not significantly better than low-dose ICSs. Similar results were found when a composite of severe and moderate exacerbations was considered.
Loymans RJB et al. Comparative effectiveness of long term drug treatment strategies to prevent asthma exacerbations: Network meta-analysis. BMJ 2014 May 13; 348:g3009. (http://dx.doi.org/10.1136/bmj.g3009)
Comment
In this extensive meta-analysis, low-dose ICS monotherapy was superior to all other single-agent strategies for preventing asthma exacerbations, and only ICSs combined with long-acting β-agonists lowered risk for severe exacerbations better than low-dose ICS monotherapy. These results affirm the central role of ICSs in managing patients with asthma and are consistent with current NIH guidelines.