Combination of inhaled corticosteroids and beta(2)-agonists in asthma - Clinical and economic implications

The current asthma management guidelines recommend that all but patients with the mildest disease should be treated with a combination of inhaled corticosteroids and beta(2)-agonists, the latter preferably on an as-needed basis, This article reviews the clinical implications of these recommendations, and also examines the potential economic and quality of life (QOL) effect of this therapy. There is a large body of evidence showing that the addition of inhaled corticosteroids to the use of inhaled beta(2)-agonists improves the lung term course of asthma, in both adults and children, Most studies suggest that asthma deteriorates after reducing or discontinuing the use of inhaled corticosteroids, The use of corticosteroids in the early, mild stages of the disease has renewed concerns about the adverse effects of long term use of inhaled corticosteroids, especially in children. The shift in treatment towards the combined use of inhaled corticosteroids and beta(2)-agonists has increased the expenditures for asthma drugs, However, a number of studies indicate that the higher acquisition costs of inhaled corticosteroids can be largely offset by a reduction in other healthcare costs, Inhaled corticosteroids are associated with reduced need for hospitalisation, emergency room visits, physician contacts and medications, In patients with moderate to severe disease at least 75% of the savings are due to a reduction in the costs of hospitalisations. When the production gains due to reduced absence from work and school are taken into account, combined inhaled corticosteroid and beta(2)-agonist treatment certainly leads to net savings. Studies of the cost-effectiveness of combination treatment in patients with mild disease are not available. Although the number of studies looking at the effect on QOL is rather limited, there are strong indications that the combined use of inhaled corticosteroids and beta(2)-agonists also improves QOL. Further research is warranted to determine whether it is more cost-effective to combine inhaled corticosteroids with on-demand or continuous use of beta(2)-agonists, and whether it is possible for patients with mild disease to be treated with inhaled corticosteroids only periodically when asthma is deteriorating, instead of continuously. Further research is also needed to determine whether, in patients whose asthma is poorly controlled with a low dosage of inhaled corticosteroids, increasing the corticosteroid dosage is more or less cost-effective than adding a long-acting beta(2)-agonist.