TREATMENT OF THE UNUSUALLY DIFFICULT ASTHMATIC PATIENT

Various practice parameters have emphasized a step-wise approach to th e treatment of asthma utilizing high doses of inhaled corticosteroids, Le., 2000 ug per day far the most difficult-to-manage asthmatic patie nt, along with maximum bronchodilator therapy. The use of such vigorou s therapy presupposes that various triggers that perpetuate asthma hav e been considered and hopefully eliminated or diminished, such as occu pational incitants, gastroesophageal reflux, and concomitant medicatio n such as beta blockers and perhaps difficult-to-recognize allergen st imulation. As new therapies emerge, their role in the treatment of a s evere subgroup of the population remains uncategorized and will only b e clarified with personal experience and appropriate double-blind stud ies. For example, there are data to support the concept that salmetero l plus moderate dose aerosol corticosteroids is superior to high dose corticosteroid aerosols. Theoretically the use of anti-leukotrienes fo r a patient with aspirin idiosyncrasy may be superior to other combina tions as would be conjectured from aspirin challenge data. Lidocaine h as recently been employed in severe asthmatics, and preliminary data s uggest benefit. The purpose of this review is to summarize some of our knowledge regarding medications that are either steroid-sparing or th at might be useful in a subgroup of asthmatic patients with severe ast hma.