Page 38 - Comprehensive treatment of patients with glucocorticoid-dependent severe asthma

Chapter 2
elegantly described in a case report by Taylor and Hannah [75]. Recently, even beta blockers have been proposed for the treatment of asthma, and trials investigating potentially beneficial effects of these drugs in chronic asthma are now underway [76-78]. Altogether current evidence suggests that short- acting beta-2-agonists should preferably not be prescribed on a regular basis, but only as needed, and overuse should be controlled and avoided.
Long acting beta-2-agonists
The benefits of adding long-acting beta-2-agonists to inhaled corticosteroids in patients with moderately severe asthma have been convincingly demonstrated in many controlled studies, and include a better control of asthma with a significant reduction in the rate of exacerbations [79-81].
On the other hand, in large epidemiological and post marketing studies [82;83] the use of long acting beta-2-agonists has been associated with an increased risk of severe exacerbations, leading to hospitalizations as well as asthma deaths, in particular if not combined with inhaled corticosteroids [84-87].
In February 2010, the FDA required the manufacturers of long acting beta-2- agonists to revise their drug labels because of these undesirable effects [88;89]. Currently, several large multicenter trials requested by the FDA are underway to clarify the safety risk associated with long-acting beta-2-agonists when used concurrently with inhaled corticosteroids [89].
Thus, although in severe asthma it is hard to imagine how to treat patients adequately without long acting beta-2-agonists, caution is warranted about potential serious adverse effects in susceptible individuals [90]. Instruction about the safe-use of long acting beta-2-agonists and close monitoring are needed in order to identify when the risk of adverse events has become greater than the potential benefit [84].
Anticholinergic agents
Anticholinergic agents may be used as alternative bronchodilators for asthmatic patients who experience adverse effects from beta-2-agonists [91], or who use beta-2-agonists in too large amounts. Recently, anticholinergic agents have also shown to have beneficial effects on lung function when given on top of maximal recommended treatment with inhaled corticosteroids and
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