Page 128 - Comprehensive treatment of patients with glucocorticoid-dependent severe asthma

Chapter 7
Discussion
We demonstrated that an Internet-based management tool had the potential of decreasing total corticosteroid consumption in patients with steroid dependent asthma as compared with conventional treatment over a period of 6 months, without compromising asthma control or asthma-related quality of life. These results suggest that a strategy based on intensive internet monitoring of objective measures of asthma control should be considered as a safe and feasible way to adjust the oral corticosteroids dose in patients with severe asthma.
In the literature, there is hardly any information available on how to safely taper oral corticosteroids in asthma after prolonged use. Adjustment of inhaled corticosteroids guided by objective parameters of airway disease has been addressed by several other studies. The use of airway responsiveness [26], eosinophils in induced sputum [27] and FeNO [28, 29] appeared to be superior over usual care in most studies, although for FeNO there has been some controversy [30-32]. In contrast to these previous studies, the aim of our study was not to evaluate the value of ACQ or FeNO as such in adjusting the corticosteroid dose but to use these measures as part of an integrated, multifaceted approach including internet-supported monitoring and continuous supervision by a specialized asthma nurse.
In the present study we compared the effectiveness of two clinical strategies using a pragmatic approach [19] according to CONSORT guidelines [22]. In this approach the use of placebo or sham is not recommended to assess the relative benefits versus harms of different treatment strategies, in order to make it more representative of actual practice [19]. Patients in our study were aware of their randomization group and knew that they would receive tapering instructions either on a weekly base from the computer or by the treating physician on a monthly base. Therefore blinding the patients would not only be futile but also diverge from the pragmatic concept.
One could argue that belief in the novel internet approach, extra effort and optimism might have positively influenced the effectiveness of the internet- based management tool. However, given the fact that the patients’ global
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