Benefits of fixed-dose combination therapy with inhaled corticosteroids and long-acting bronchodilators as initial maintenance therapy in the management of asthma

Revised Australian guidelines for asthma management were released by the National Asthma Council (NAC) in 2006. One area where clinical opinion and trial data have changed recently concerns the place of fixed-dose combination (FDC) therapy with inhaled corticosteroid (ICS) and long-acting beta(2)-agonists as initial maintenance therapy. A systematic review of the literature commissioned by the NAC and undertaken by the University of Tasmania addressed several questions, including whether there was evidence for the use of FDC therapy as first-line asthma treatment in steroid-naive patients. Nineteen relevant studies were identified, from which 20 comparisons contributed to the analyses. The definition of steroid-naive ranged from no ICS therapy over the preceding 1 month to no ICS therapy ever. FDC therapy was effective in subjects who were steroid-naive and was more effective than an equivalent dose of ICS, irrespective of the definition of steroid-naivety. Compared with ICS alone, FDC therapy increased mean FEV1 by 140 mL, mean morning PEF by 21 L/min and mean evening PEF by 20 L/min. There was a mean increase of 9.8% in symptom-free days, associated with a greater reduction in rescue medication use of -0.12 puff/24 h. FDC therapy was not superior to ICS alone for prevention of withdrawals or exacerbations requiring systemic corticosteroids. Adverse events were similar for FDC therapy and ICS, whether ICS were administered at the same or an increased dose. FDC therapy is effective as first-line treatment in steroid-naive subjects and is superior to ICS alone for most outcomes, irrespective of the period of time since last exposure to ICS.