不同 “降阶梯治疗”战略在轻度持续性哮喘中的应用
2007/08/01
支气管哮喘诊治指南指出：对有持续症状的哮喘患者，建议使用吸入皮质类固醇、“阶梯治疗”原则，最终达到使用最少药物维持症状控制。然而，当支气管哮喘患者症状控制后，是否可以将每天吸入皮质类固醇2次，“降级”为孟鲁司特（montelukast）每日1次，或1天1次丙酸氟替卡松（fluticasone propionate）联合应用沙美特罗(salmeterol)，尚未确定。
作者随机、双盲将通过吸入fluticasone(100ug，Bid) 后得到很好控制的哮喘患者分为三组，并给予为期16周的不同的治疗方案：第一组患者(169例)继续接受原方案（即fluticasone 100ug，Bid）治疗；第二组患者(166例)接受montelukast(每晚5或10毫克)；第三组患者(165例)每晚fluticasone(100 ug)联合salmeterol(50 ug)治疗。结果是在第一组继续接受原方案（即fluticasone 100ug，Bid）的患者和第三组接受每晚fluticasone(100 ug)联合salmeterol(50 ug)治疗的患者中，有近20%的患者治疗失败；而在第二组患者（接受每晚5或10毫克的montelukast）中，有近30.3%的患者治疗失败。两者之间有显著性的差异。观察期间，三组患者无哮喘症状天数的百分率比(78.7%至85.8%)则相近。
因此，作者认为当支气管哮喘患者症状控制后，可以将每天吸入fluticasone2次，“降级”为1天1次的fluticasone 联合应用沙美特罗(salmeterol)。但如果改为每日1次的montelukast治疗，则会增加治疗的失败率，不能有效的控制哮喘。值得一提的是接受每日1次的montelukast治疗的患者在78.8%的治疗观察期中没有出现哮喘症状。
（张清玲 广州医学院第一附属医院 广州呼吸疾病研究所 510120 摘译）
（N Engl J Med. 2007 ;356:2027-2039）
The American Lung Association Asthma Clinical Research Centers.Randomized Comparison of Strategies for Reducing Treatment in Mild Persistent Asthma. N Engl J Med. 2007 May 17;356(20):2027-2039
Background：Treatment guidelines recommend the use of inhaled corticosteroids in patients with asthma who have persistent symptoms and the “stepping down” of therapy to the minimum needed to maintain control of asthma. Whether patients with asthma that is well controlled with the use of inhaled corticosteroids twice daily can receive a stepdown treatment with once-daily montelukast (our primary hypothesis) or once-daily fluticasone propionate plus salmeterol (our secondary hypothesis) has not yet been determined.
Methods：We randomly assigned 500 patients with asthma that was well controlled by inhaled fluticasone (100 μg twice daily) to receive continued fluticasone (100 μg twice daily)(169 patients), montelukast (5 or 10 mg each night) (166 patients), or fluticasone(100 μg) plus salmeterol (50 μg) each night (165 patients). Treatment was administered for 16 weeks in a double-blind manner. The primary outcome was the time to treatment failure.
Results：Approximately 20% of patients assigned to receive continued fluticasone or switched to treatment with fluticasone plus salmeterol had treatment failure, as compared with 30.3% of subjects switched to montelukast. The hazard ratio for both comparisons was 1.6 (95% confidence interval, 1.1 to 2.6; P = 0.03). The percentage of days on which patients were free of asthma symptoms (78.7 to 85.8%) was similar across the three groups.
Conclusions：Patients with asthma that is well controlled with the use of twice-daily inhaled fluticasone can be switched to once-daily fluticasone plus salmeterol without increased rates of treatment failure. A switch to montelukast results in an increased rate of treatment failure and decreased asthma control; however, patients taking montelukast remained free of symptoms on 78.7% of treatment days.
上一篇：
应用布地奈德福莫特罗作为缓解药物对哮喘急性加重作用的随机双盲对照研究
下一篇：
按需联合吸入二丙酸氯地米松、沙丁胺醇在在轻度持续哮喘中的应用
