What are the alternatives to increasing inhaled corticosteroids for the long term control of asthma?

The Global Initiative for Asthma (GINA) guidelines stated the therapeutic g oals fur the management of asthma and, through a stepwise approach to treat ment, defined the various grades of asthma severity and the therapeutic opt ions available to the clinician at each step. This article considers the op tions at step 3; the management of a patient with poorly controlled asthma who is already taking low-dose inhaled corticosteroids. Before considering a change in therapy, the clinician should rule out alter native diagnoses, confirm compliance with treatment, explore potential exac erbants in the patient's environment and, where possible, remove them. If a change in medication is necessary, the choice of drug will depend on the t herapeutic goal that needs to be achieved. If the most important goal is th e control of symptoms and optimisation of lung function, most studies suppo rt the addition of a long-acting beta (2)-agonist to low dose inhaled corti costeroids. If recurrent severe exacerbations are a major feature of the po or control, increasing the dosage of inhaled corticosteroids may he most ef fective. The addition of a leukotriene antagonist may be the best choice if exercise-induced symptoms are prominent or in the setting of aspirin-sensi tive asthma. General recommendations supported by the findings of large therapeutic tria ls do not allow for significant variability in the individual response to a particular drug. Receptor polymorphisms have recently been discovered that may account for variability in the response to beta (2)-agonists and leuko triene receptor antagonists. However, until more is known about the reasons behind this variability, a therapeutic trial may be the most effective way of determining the best drug for an individual patient. One of the key developments in asthma over the past decade has been the acc eptance of the concept of asthma as a chronic inflammatory disorder of the airways. However, the long term significance of this inflammation is not cl ear and the importance of control of inflammation beyond the suppression of symptoms, reduction of exacerbation frequency and the optimisation of lung function has not been established.