Remember When We Used to Prescribe Inhaled Steroids for Asthma and COPD?

Press Release: Annual Conference of the Universal College of Chest Physicians October 2085; New Chicago, Mars.

The annual conference enjoyed another record attendance today as attendees flocked to Dr. Ramachandran III’rds keynote address reviewing exploits of physicians in the early part of the century. Dr. Ramachandran highlighted some key decisions and their consequences, such as the ACGME’s decree in 2032 that all residents should be swaddled before their scheduled hourly nap times. This of course led to the now infamous Great Hospital Apocalypses of 2033, 2034, and 2035.

Perhaps nearly as intriguing was the plight of inhaled corticosteroids for the treatment of respiratory diseases like asthma and COPD in the beginning of the 21st century. The period began with greater awareness and concern regarding the use of long acting beta agonist (LABA) bronchodilators such salmeterol. That risk was highlighted by findings published in the SMART trial (access through Chest archives here). There was increased concern regarding the potential harm caused by LABA which culminated in the placement of warnings on medications which contained LABA bronchodilators. These medications, experts said, were to be prescribed with extreme caution because of the possible increase in harm, particularly among children.

Scholars of the early 21st century thus highly recommended that asthmatics, especially children, be started on steroid inhalers before having to resort to using inhaled LABAs. Many also theorized that inhaled steroids had a protective effect when combined with LABA’s, possibly ameliorating their potential danger. Thus many at the time recommended a strategy of not using LABA inhalers at all, unless also simultaneously prescribing an inhaled steroid.

However, problems with this approach started to appear late in the first decade of the century. The TORCH study, a trial using combined inhaled LABA/inhaled steroids in adults with COPD suggested that there was an increased incidence of pneumonia among those treated with inhaled steroids. Early in the second decade a pivotal study then demonstrated that asthmatic children treated with inhaled steroids ended up being about half an inch shorter than they might have otherwise been (interestingly, a later study in 2035  correlated the reduced height with a statistically significant decrease in NBA dunking).

Not long after that study was published, the academic community was rocked yet again when a study published in Chest illustrated an increased risk of pneumonia among asthmatics using inhaled steroids. While it had been increasingly thought that inhaled steroids were a risk factor for pneumonia in people with COPD, this relationship had not been demonstrated among those with asthma. Dr. McKeever and her colleagues from University of Nottingham, England found that a dose-response relationship existed among those with asthma using inhaled corticosteroids, with an increased risk of pneumonia seen with higher doses of inhaled steroids.

This of course raised several questions for doctors of the time. When should inhaled steroids be initiated, or decreased, or stopped? Should they still truly be considered protective? Perhaps, thought physicians, they should be reserved for those asthmatics whose symptoms are the most poorly controlled, and then decreased or stopped as soon as possible. Interestingly, that sounded very much like the approach recommended for LABA’s at that time, the side effects of which were the very things that inhaled steroids were surmised to protect against!

So what did doctors do after that? How did they use corticosteroids in light of these findings? Tune your brain wave scanner to Dr. Ramachandran IIIrd’s live Twelepathy chat tomorrow at 8am to find out what happened to inhaled steroids as well as everything you wanted to know about the Martian Bird Flu Epidemic of 2053.