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TAKING STEROIDS (OR NOT) |
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Appreciating the benefit of any medicine improves compliance. It is unfortunate that the beneficial effects of ICS, or the adverse consequences of stopping them, appear so slowly that many asthmatics do not notice much difference, and feel unrewarded for the bother of taking them. Relievers, in contrast, provide obvious relief within minutes. So we are battling against human nature to achieve compliance. Appreciating the extent of the problem can be helpful. In a U.K. general practice, only 7 out of 47 asthmatics collected enough of their ICS during one year to enable them to take the prescribed dosage.[1] In a Glasgow study of asthmatic pre-schoolers, an electronic device on each inhaler showed that most children actually took only 77% of prescribed doses, with morning and evening doses both taken only on half the days.[2] Another electronically controlled study found only 58% compliance after 13 weeks. [3] These and other reports were based on short-term studies. A long-term
study in Norway has now reported the efforts of 89 children with mild
asthma, age 7-16 years, over a period of 2¼ years.[4] It found
that drug-compliance diminished significantly over time. During the
first three months, compliance (i.e.% of doses taken), was 77% for those
on active medication (Pulmicort™), and 78% for those on placebo.
At 9 months these figures fell respectively to 54% and 57%; at 27 months
they were 49% and 32%. Even at these levels, the authors remind us that
involvement in a clinical trial is known to be a wonderful motivating
factor for good compliance; in the general population of asthmatics
it is likely to be even less than 49% after two years. The lowest effective dose of ICS for each individual child, achievable by ‘back-titration’, was not part of the trial plan; (after 3 months of stable asthma, this should now be the norm). It remains possible that some of the children no longer needed 200 mcg of Pulmicort daily, and would have remained stable on 100 mcg, which is what many must have been taking in defiance of instructions! Rather confusing. What emerges is that a lot of asthmatics fail to take their ICS as prescribed; many of these fail to achieve maximum benefit, whilst others, unknown to their G.P., (but possibly appreciated by themselves!) may actually be getting all they need, provided they take a reduced dose in a regular manner. Growth retardation in children can be obviated The minimal growth retardation that can occur in pre-pubertal children taking 400 mcg of inhaled steroid daily doesn’t really matter at all; it has been shown that any deficit is made up after puberty; and anyway, uncontrolled asthma would almost certainly have the same or a greater effect. However, it is likely to be comforting to parents who have heard about this, to learn that even this unimportant growth-reduction can be obviated by reducing the inhaled steroid dose to 200 mcg daily and adding a ‘controller’ drug. A study of 24 children 6–13 years old in Denmark, showed that growth (measured by length of lower leg), was significantly greater when the subjects took only 200 mcg of Pulmicort™, together with 12 mcg of Oxis™ (both as a dry powder by Turbohaler™), than when they took 400 mcg of Pulmicort daily.[5] This was a double-blind, placebo-controlled crossover trial, with six weeks on each regimen for all children. Before entering the trial, asthma had been controlled by 400 mcg daily of Pulmicort.
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