The risk of asthma exacerbation after stopping low-dose inhaled corticosteroids

A systematic review and meta-analysis of randomized controlled trials

Matthew A Rank, John B. Hagan, Miguel Park, Jenna C. Podjasek, Shefali A. Samant, Gerald W. Volcheck, Patricia J. Erwin, Colin Patrick West

Research output: Contribution to journalArticle

52 Citations (Scopus)

Abstract

Background: Current asthma guidelines suggest that patients and their providers consider decreasing or stopping controller medications when asthma is stable. Objective: We sought to estimate the risk of asthma exacerbation in patients who stop low-dose inhaled corticosteroids (ICSs) compared with those who continue ICSs in randomized controlled trials. Methods: We identified relevant trials from a systematic review of English-language and non-English-language articles using MEDLINE, EMBASE, and CENTRAL (inception to January 21, 2012). Articles were screened at the abstract and full-text level by 2 independent reviewers. We included randomized controlled trials with a stable asthma run-in period of 4 weeks or more, an intervention to stop or continue ICSs, and a follow-up period of at least 3 months. We pooled results using a random-effects meta-analysis. Results: The search strategy identified 1798 potential articles, of which 172 were reviewed at the full-text level and 7 met the criteria for inclusion. The relative risk for an asthma exacerbation in patients who stopped ICSs compared with those who continued use was 2.35 (95% CI, 1.88-2.92; P < .001; I2 = 0%), as determined by using data pooled from trials with a mean follow-up of 27 weeks. The pooled absolute risk difference for an asthma exacerbation was 0.23 (95% CI, 0.16-0.30; P < .001; I2 = 44%). Patients who discontinued ICSs also had a decreased FEV1 of 130 mL (95% CI, 40-210 mL; P = .003; I2 = 53%), a decreased mean morning peak expiratory flow of 18 L/min (95% CI, 6-29 L/min; P = .004; I2 = 82%), and an increased mean standardized asthma symptom score of 0.43 SDs (95% CI, 0.28-0.58 SDs; P < .001; I2 = 0%). Conclusion: Patients with well-controlled asthma who stop regular use of low-dose ICSs have an increased risk of an asthma exacerbation compared with those who continue ICSs.

Original languageEnglish (US)
JournalJournal of Allergy and Clinical Immunology
Volume131
Issue number3
DOIs
StatePublished - Mar 2013

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Meta-Analysis
Adrenal Cortex Hormones
Asthma
Randomized Controlled Trials
Language
MEDLINE
Guidelines

Keywords

  • antiasthma agents
  • Asthma
  • cessation
  • clinical trial
  • decrease
  • discontinue
  • glucocorticoids
  • step down
  • wean
  • withdraw

ASJC Scopus subject areas

  • Immunology and Allergy
  • Immunology

Cite this

The risk of asthma exacerbation after stopping low-dose inhaled corticosteroids : A systematic review and meta-analysis of randomized controlled trials. / Rank, Matthew A; Hagan, John B.; Park, Miguel; Podjasek, Jenna C.; Samant, Shefali A.; Volcheck, Gerald W.; Erwin, Patricia J.; West, Colin Patrick.

In: Journal of Allergy and Clinical Immunology, Vol. 131, No. 3, 03.2013.

Research output: Contribution to journalArticle

Rank, Matthew A ; Hagan, John B. ; Park, Miguel ; Podjasek, Jenna C. ; Samant, Shefali A. ; Volcheck, Gerald W. ; Erwin, Patricia J. ; West, Colin Patrick. / The risk of asthma exacerbation after stopping low-dose inhaled corticosteroids : A systematic review and meta-analysis of randomized controlled trials. In: Journal of Allergy and Clinical Immunology. 2013 ; Vol. 131, No. 3.
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abstract = "Background: Current asthma guidelines suggest that patients and their providers consider decreasing or stopping controller medications when asthma is stable. Objective: We sought to estimate the risk of asthma exacerbation in patients who stop low-dose inhaled corticosteroids (ICSs) compared with those who continue ICSs in randomized controlled trials. Methods: We identified relevant trials from a systematic review of English-language and non-English-language articles using MEDLINE, EMBASE, and CENTRAL (inception to January 21, 2012). Articles were screened at the abstract and full-text level by 2 independent reviewers. We included randomized controlled trials with a stable asthma run-in period of 4 weeks or more, an intervention to stop or continue ICSs, and a follow-up period of at least 3 months. We pooled results using a random-effects meta-analysis. Results: The search strategy identified 1798 potential articles, of which 172 were reviewed at the full-text level and 7 met the criteria for inclusion. The relative risk for an asthma exacerbation in patients who stopped ICSs compared with those who continued use was 2.35 (95{\%} CI, 1.88-2.92; P < .001; I2 = 0{\%}), as determined by using data pooled from trials with a mean follow-up of 27 weeks. The pooled absolute risk difference for an asthma exacerbation was 0.23 (95{\%} CI, 0.16-0.30; P < .001; I2 = 44{\%}). Patients who discontinued ICSs also had a decreased FEV1 of 130 mL (95{\%} CI, 40-210 mL; P = .003; I2 = 53{\%}), a decreased mean morning peak expiratory flow of 18 L/min (95{\%} CI, 6-29 L/min; P = .004; I2 = 82{\%}), and an increased mean standardized asthma symptom score of 0.43 SDs (95{\%} CI, 0.28-0.58 SDs; P < .001; I2 = 0{\%}). Conclusion: Patients with well-controlled asthma who stop regular use of low-dose ICSs have an increased risk of an asthma exacerbation compared with those who continue ICSs.",
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