Jk. Sont et al., Clinical control and histopathologic outcome of asthma when using airway hyperresponsiveness as an additional guide to long-term treatment, AM J R CRIT, 159(4), 1999, pp. 1043-1051
According to international guidelines, the level and adjustment of antiinfl
ammatory treatment for asthma are based solely on symptoms and lung functio
n. We investigated whether a treatment strategy aimed at reducing airway hy
perresponsiveness (AHR strategy) in addition to the recommendations in the
existing guidelines (reference strategy) led to: (1) more effective control
of asthma; and (2) greater improvement of chronic airways inflammation. To
accomplish this, we conducted a randomized, prospective, parallel trial in
volving 75 adults with mild to moderate asthma who visited a clinic every 3
mo for 2 yr. At each visit, FEV1 and AHR to methacholine were assessed, an
d subjects kept diaries of symptoms, beta(2)-agonist use, and peak expirato
ry flow (PEF). Medication with corticosteroids (four levels) was adjusted a
ccording to a stepwise approach (reference strategy), to which four severit
y classes of AHR were added (AHR strategy). At entry and after 2 yr, bronch
ial biopsies were obtained by fiberoptic bronchoscopy. Patients treated acc
ording to the AHR strategy had a 1.8-fold lower rate of mild exacerbations
than did patients in the reference strategy group (0.23 and 0.43 exacerbati
on/yr/patient, respectively). FEV1 also improved to a significantly greater
extent in the AHR strategy group (p less than or equal to 0.05). In bronch
ial biopsies this was accompanied by a greater reduction in thickness of th
e subepithelial reticular layer in the AHR strategy group than in the refer
ence strategy group (mean difference [95% confidence interval (CI): 1.7 mu
m (0.2 to 3.1) mu m]). The changes in AHR in both strategy groups were corr
elated with eosinophil counts in the biopsies (r = -0.48, p = 0.003). We co
nclude that reducing AHR in conjunction with optimizing symptoms and lung f
unction leads to more effective control of asthma while alleviating chronic
airways inflammation. This implies a role for the monitoring of AHR or oth
er surrogate markers of inflammation in the long-term management of asthma.