Volume 121, Issue 5 , Pages 1293-1294, May 2008
Reply
Article Outline
To The Editor:
I am grateful for the comments by Dr Stirling1 on my article,2 which highlighted the necessity of viewing the complexity of asthma and called for a paradigm shift in our understanding of this complexity. My article opposed the common paradigm viewing asthma as an eosinophil-dominated central airway inflammatory disorder, in which anti-inflammatory treatment is more or less equivalent to corticosteroid therapy.
It is true that inhaled corticosteroid (ICS) therapy has resulted in a dramatic improvement in asthma control in many patients. However, it is also true that a large number of patients do not achieve acceptable control after treatment with modern ICS therapy, even when it is combined with long-acting β2-agonist (LABA) therapy in increasing doses.3 One reason for this shortcoming could, of course, be that the inhaled medication does not reach the peripheral airways in sufficient concentrations.4 However, I strongly believe that it is also due to the fact that the inflammation seen in the peripheral airways is different in some respects; it can be nonresponsive to ICSs and thus requires alternative treatment approaches.
Airway remodeling is also very complex. I do not propose that all structural changes occurring in the airways referred to as “airway remodeling” are irreversible and nonresponsive to ICS therapy. However, it is clear that some are not. The Childhood Asthma Management Program study5 and the recently published observation by Guilbert et al6 nicely display the shortcomings of ICSs in preventing the decrease of lung function, as well as in providing long-term control of the disease.
Unfortunately, our understanding of asthma seems to be very much influenced by what the big pharmaceutical companies are currently marketing. Before the ICS/LABA era, asthma was considered by some to be more or less a corticosteroid deficiency syndrome. Nowadays, it is more popular to talk about gaining clinical control by combining ICSs with a controller (ie, LABAs). However, we need to face the fact that even today very few patients with adult asthma recover completely from their disease, either spontaneously or after treatment.7, 8 Thus it is clear that there is still room for improvement, and it is certainly time for a paradigm shift. Such change is necessary before we can take action to improve outcomes for all patients with asthma.
References
- . Airway inflammation: an important marker of control for asthma guidelines?. J Allergy Clin Immunol. 2008;121:1293
- . Time for a paradigm shift in asthma treatment: from relieving bronchospasm to controlling systemic inflammation. J Allergy Clin Immunol. 2007;120:1269–1275
- Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. Am J Respir Crit Care Med. 2004;170:836–844
- . Distribution of inhaled fluticasone propionate between human lung tissue and serum in vivo. Eur Respir J. 1997;10:1496–1499
- . Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med. 2000;343:1054–1063
- Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med. 2006;354:1985–1997
- . Remission of asthma in the middle aged and elderly: report from the Obstructive Lung Disease in Northern Sweden study. Thorax. 1999;54:611–613
- . Outcome and severity of adult onset asthma—report from the obstructive lung disease in northern Sweden studies (OLIN). Respir Med. 2007;101:2370–2377
Disclosure of potential conflict of interest: The author has declared that he has no conflict of interest.
PII: S0091-6749(08)00422-3
doi:10.1016/j.jaci.2008.02.036
© 2008 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
Volume 121, Issue 5 , Pages 1293-1294, May 2008
