Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

High-dose intramuscular triamcinolone improved lung function and decreased hospital use compared with low-dose oral prednisone in chronic, life-threatening asthma

ACP J Club. 1991 Jul-Aug;115:2. doi:10.7326/ACPJC-1991-115-1-002


Source Citation

Ogirala RG, Aldrich TK, Prezant DJ, et al. High-dose intramuscular triamcinolone in severe, chronic, life-threatening asthma. N Engl J Med. 1991 Feb 28;324:585-9.


Abstract

Objective

To evaluate the effectiveness of high-dose intramuscular triamcinolone in patients with chronic, life-threatening asthma when compared with low-dose oral prednisone.

Design

Randomized, double-blind, crossover study with each of the 2 treatment periods lasting 3 months separated by a 3-month washout period.

Setting

Not described.

Patients

Patients had severe asthma with worsening of symptoms for 1 to 7 years and recurrent life-threatening exacerbations despite continuous oral prednisone therapy. Patients with contraindications to corticosteroids or with serious nonrespiratory disease were excluded. Of the 15 patients randomized, 12 (80%) completed the study (8 women and 4 men).

Intervention

Patients received either intramuscular triamcinolone acetonide for the first 3 days (120 mg/d) and 3 placebo tablets daily for 3 months or an injection of placebo daily for 3 days and three 5-mg tablets of prednisone daily for 3 months. A 3-month washout period followed, after which participants crossed over to the alternate treatment program. Patients were allowed to take additional prednisone tablets if their asthma worsened. Patients were told to inhale triamcinolone acetonide (400 mg, 4 times daily) throughout the study. Study treatments were discontinued during any hospitalizations for acute exacerbations of asthma.

Main outcome measures

Mean forced expiratory volume in 1 second (FEV1) and number of emergency department visits and hospitalizations.

Main results

FEV1 values improved in patients who received triamcinolone first compared with those who received prednisone first (P < 0.02). For peak expiratory flow rate, the average weekly percentage of the predicted value in the 3 months after treatment with triamcinolone was 92% (SE 6.9%), compared with 75% (SE 5.9%) after treatment with prednisone (P < 0.05). There were 21 emergency department visits and 10 hospitalizations during the prednisone period compared with none during the triamcinolone period (P < 0.05). 3 patients required intubation during or after the prednisone period, and none after triamcinolone.

Conclusion

Injections of high-dose triamcinolone (120 mg/d for 3 days) improved pulmonary function and reduced the number of emergency department visits and hospitalizations in patients with chronic, life-threatening asthma when compared with low-dose oral prednisone (15 mg/d for 3 months).

Source of funding: No external funding.

Address for article reprint: Dr. R.G. Ogirala, Pulmonary Division, Centennial Building, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467-2490, USA.


Commentary

Asthma of the severity seen in this study is infrequent but well recognized. It has not been possible to define optimal treatment for these patients because of the lack of sound trials. However, there is increasing consensus to treat asthma with anti-inflammatory drugs, particularly corticosteroids (1), and the study of Ogirala and colleagues shows that severe asthma can be improved by higher doses of corticosteroids. The important question is how to deliver corticosteroids in sufficient dose to control asthma and yet minimize side effects.

This is the second study of this design to show benefit of injected triamcinolone compared with oral prednisone for treatment of severe asthma (2). Triamcinolone appears to be more effective than an equivalent dose of prednisone, but the reason for this is not known.

The results of this study and of the previous one should be evaluated with caution. Triamcinolone was not compared with an optimal alternative treatment regimen. It is not clear that the patients had an adequate trial of high doses of inhaled steroids, and the dose of prednisone used was too low when FEV1 was < 50% of the predicted value (6 patients). There is also the general difficulty of using results of short-term, crossover trials on a small number of patients as evidence for advising long-term therapy. Readers should watch for other studies of this intervention and may want to apply these findings to patients for whom conventional treatment is failing.

Gerard Ryan, MD
Sir Charles Gairdner HospitalNedlands, Australia


References

1. Hargreave FE, Dolovich J, Newhouse MT. The assessment and treatment of asthma: a conference report. J Allergy Clin Immunol. 1990;85:1098-111.

2. Willey RF, Fergusson RJ, Godden DJ, Crompton GK, Grant IW. Comparison of oral prednisone and intramuscular depot triamcinolone in patients with severe chronic asthma. Thorax. 1984; 39:340-4.