Adding long-acting beta-agonists to inhaled corticosteroids after discharge from the emergency department for acute asthma: a randomized controlled trial.

BACKGROUND: Relapses of asthma following emergency department discharge can be reduced with oral and inhaled corticosteroids (ICSs), but the benefits of long-acting beta-agonists (LABAs) are unclear.

OBJECTIVES: To determine whether the addition of a LABA reduces relapses in patients with acute asthma.

METHODS: This was a randomized, controlled, double-blind trial of 137 patients, aged 18-55 years, conducted in four Canadian EDs. Patients receiving high-dose ICSs or oral corticosteroids, and those who were medically unstable, were excluded. Patients were randomized to either fluticasone 1,000 microg/day with salmeterol 100 microg/day or fluticasone 1,000 microg/day alone. All patients were discharged on seven days of oral prednisone. The main outcome measure was relapse at 21 days.

RESULTS: Both groups had similar baseline characteristics. After 21 days, seven of 69 patients (10.1%) treated with fluticasone/salmeterol and ten of 68 patients (14.7%) treated with fluticasone experienced a relapse (p = 0.42). Prior intubation, female gender, and prior use of ICSs were associated with relapse. There were no clinically or statistically significant differences in overall quality of life and individual domain scores. Fluticasone/salmeterol improved quality of life (p < 0.05) and relapses (24% to 13%; p = 0.35) in patients receiving ICSs at the time of emergency admission.

CONCLUSIONS: Outpatient treatment with a short course of systemic corticosteroids combined with ICSs is adequate for most patients with asthma discharged from the emergency department; those already receiving ICS agents may benefit from ICS/LABA combination therapy to improve quality of life. Larger studies are needed to confirm the role of inhaled LABAs in acute asthma.