BMJ  2003;327:E73 (4 October), doi:10.1136/bmjusa.01100003 (published 13 September 2002)

BMJ USA: Letter

RAPID RESPONSES FROM BMJ.COM

Anti-inflammatory end points

This article originally appeared in BMJ USA

Editor—In the meta-analysis by Holt et al, none of the studies measured airway inflammation or hyperresponsiveness, which are fundamental to asthma pathophysiology. Studies with fluticasone and other inhaled corticosteroids have shown a steeper dose response for effects on airway hyperresponsiveness than for other outcomes, such as lung function, symptoms, and rescue use.^1-4 Indeed, over a prospective two-year follow-up, titrating the inhaled corticosteroid dose against airway hyperresponsiveness in addition to lung function, symptoms, and rescue use, resulted in more effective control and reduced airway remodeling.⁵ The data of Holt et al merely indicate the lack of sensitivity of conventional measures of asthma control, which do not reflect the underlying asthmatic disease process.

Asthma and Allergy Research Group, Ninewells University Hospital, Dundee, UK b.j.lipworth{at}dundee.ac.uk

In reply—Lipworth et al raise an important issue: Which are the relevant clinical outcome measures that should be assessed in studies of the efficacy of inhaled corticosteroids in asthma?¹ We do not concur that conventional measures of asthma control lack sensitivity and do not reflect the underlying disease process, or their inference that indirect measurements, such as bronchial hyperresponsiveness, are preferable.

In our opinion, bronchial hyperresponsiveness is not an established outcome measure; it is neither recommended nor routinely used in assessing of asthma severity for both scientific and practical reasons.^2-4 Furthermore, evidence that bronchial hyperresponsiveness has a differing dose-response relationship for inhaled corticosteroids in asthma is equivocal at best.^5-7

For the reasons provided in our manuscript, we conclude that for the recognized, validated clinical outcome measurements most of the benefit of inhaled fluticasone is achieved with a total daily dose of around 100 to 250 µg/day.

Wellington Asthma Research Group, Wellington, New Zealand shaun{at}p3research.co.nz

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