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Pulmonary & Critical Care Bulletin
Vol. VII, No. 3, July 15, 2001
In this issue :

From Editor's Desk

(Dr. Uma Maheswari,)

(R. S. Bedi & U.S. Bedi)

16th Annual Meeting on Pulmonary and Critical Care Medicine
(Dr. S. K. Jindal)

Publihed under the auspices of:
Pulmonary C. M. E. Programme

Editorial Board :

Department of Pulmonary Medecine
Post Graduate Institute of Medical Education & Research (PGIMER) Chandigarh. INDIA-160012

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Because of socio - economic factors, adverse drug reactions, complexity of regimens and prolonged ( or life - long ) therapy, over half of asthma patients fail to take their medication regularly. Compliance with 'anti-inflammatory' or ' preventive' therapy is particularly important, as its early initiation helps in preventing disease progression. Likelihood of improved compliance is strong with once daily dose schedules.

(a) Once - daily inhaled corticosteroids
Inhaled steroids have traditionally been administered twice daily. Several recent studies suggest that once-daily dosing ( of the same cumulative daily dose ) may be equally effective, in both adults and children, particularly in patients with mild to moderate asthma.
Most of the data in published reports relate to dry-powder formulations of budesonide. In children upto 12 years of age with mild to moderate asthma, once daily doses of 200-400 micrograms, can be used. Upto 800 micrograms once daily can be used by adults. There is no evidence of local or systemic side-effects with once-daily dosing. Some data in support of once-daily dosing of other inhaled steroids, such as beclomethasone, fluticasone, flunisolide and momentasone is also available now.

Once daily inhaled corticosteroids should be prescribed in the evening since there is increasing evidence that mechanisms of inflammation are under circadian control. Many patients experience particularly troublesome symptoms at night and in the early morning. Bronchial smooth muscle hyper-responsiveness varies in a circadian fashion and is enhanced at night. The clinical relevance is that better asthma control might be achieved by evening dosing, so that rising drug levels coincide with the natural peak in airways inflammation.

(B) Oral corticosteroids
Oral steroids are not a safe first-line option for most patients in view of the large number of side - effects associated with their use.
(c) Oral Theophyllines
Low-dose oral theophyllines, sometimes used once daily in the evening, may have some weak anti-inflammatory effects.
(d) Leukotriene receptor antagonists (LTRA)
LTRAs, a relatively new class of asthma therapy, work by antagonizing the effect of endogenous leukotrienes. Leukotrienes are potent broncho-constrictors, cause recruitment of inflammatory cells and increase vascular permeability (thus causing tissue oedema and promoting mucus formation). LTRAs, effective orally, have dual antiinflammatory and bronchodilatory properties.

Montelukast is the only LTRA available for once -daily oral use (10 mg in evening) as add- on therapy and as mono-therapy (in patients with exercise-induced bronchoconstriction). Rapidity of effect (in days) and ease of administration may be relevant in terms of compliance, but cost is prohibitive and efficacy is seen in only 50% cases.

To conclude, simplifying treatment regimens by switching to once-daily dosing is one pratical way of improving compliance. Inhaled corticosteroids are current 'gold-standard' antiinflammatory therapy and other agents should only be reserved for second line add-on therapy.

R. S. Bedi & U.S. Bedi
Bedi Chest Clinic (Patiala)

R. S. Bedi & U.S. Bedi

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