Large surveillance studies or phase IV clinical studies of long-acting β-agonists (LABA) compared with placebo in
asthma patients using variable (from nil to regular) doses of inhaled
corticosteroids (ICS) have raised the issue of mortality risk in patients with
asthma taking regular LABA. There have been a number of meta-analyses and systematic reviews that have examined the risk of LABA in
asthma patients, and the general conclusion is that LABA added to ICS reduces
asthma-related hospitalizations compared with ICS alone and there is no statistical increase in mortality. However, LABA without ICS do increase mortality risk in
asthma. All reviews and analyses show a greater number of LABA deaths, but not all are statistically significant. A recent meta-analysis found LABA with concomitant ICS had a higher mortality rate in
asthma than ICS alone. The flaw in the study is the higher doses of ICS in the control arms, but the implicit message remains: the essential need for enough ICS to
control airway inflammation. We suggest that the pragmatic
solution is to have LABA only available in the same device as ICS for
asthma treatment. We do not think that a study comparing the safety of LABA plus ICS versus ICS alone in
asthma is necessary. If such a study is conducted, the measurement of morbidity from increased doses of ICS is an essential design consideration. Furthermore, the critical focus in
asthma management should not be forgotten - education of health professionals and the community of the critical role of ICS, and the need for good communication between health professionals and the
asthma patient to facilitate good
asthma control. The same arguments apply to the
asthma-with-
chronic obstructive pulmonary disease overlap syndrome in older patients. There is an urgent need to provide medical practitioners with the capability to diagnose the overlap syndrome.