Exacerbations of asthma following step-up and step-down inhaled corticosteroid and long acting beta agonist therapy in the managing asthma in pregnancy study

Abstract

Objective

Guidelines for asthma management contain a consensus recommendation that inhaled corticosteroid (ICS) dose should not be stepped down in pregnancy. However, this is not consistent with consumer preferences and pharmacological principles to minimize medication exposure during pregnancy. We investigated exacerbations after changes to ICS and long acting beta agonist (LABA) therapy in pregnant women with asthma.

Methods

Pregnant women (n = 220) were recruited to a randomized controlled trial (RCT) where maintenance treatment was adjusted monthly based on either symptoms (control group), or fractional exhaled nitric oxide (FeNO, to alter ICS) and symptoms (to alter LABA, FeNO group). Exacerbations were monitored prospectively.

Results

ICS were used by 137 (62.3%) women at some time during pregnancy. ICS dose remained unchanged in 16 women (11.7%, 95% confidence interval [CI] 7–18%), increased in 37 women (27%, 95%CI 20–35%), decreased in 34 women (24.8%, 95%CI 18%–33%), or both increased and decreased in 50 women (36.5%, 95%CI 29–45%). Exacerbations occurred within 14 days of ICS step-down in 11 women (13%, 95%CI 7.5%–22%). This was not significantly different from exacerbations occurring within 14 days of step-up, in 7 women (8.1%, 95%CI 4%–16%, P = 0.294). There were no differences between management groups. Exacerbations occurred within 14 days of step-down in 14.7% (95%CI 7%–30%) of women in the control group, and in 12% (95%CI 6%–24%) of women in the FENO group.

Conclusions

ICS step-down could be considered when eosinophilic inflammation or symptoms are low, and may be a useful management approach for women, doctors, and midwives wishing to minimize ICS exposure during pregnancy.

Keywords:

• Fractional exhaled nitric oxide
• asthma management
• inhaled steroid titration

Acknowledgements

The authors acknowledge the MAP study investigators: Peter Gibson, Vicki Clifton, Robin Taylor, Michael Hensley, Warwick Giles, Vanessa Murphy, Andy Woods and Kirsten McCaffery, and thank Heather Powell, Kelly Steel, Karen McLaughlin, Rebecca Oldham, Linda Howell, Joanne Smart, Noreen Bell and Sandra Dowley for assistance with clinical assessments and data collection, the midwives and staff of the antenatal clinic at John Hunter Hospital for their assistance during subject recruitment, and Soriah Harvey for administrative assistance and Annelies Robijn for statistical assistance.

Declaration of interest

The authors report no conflicts of interest.

Additional information

Funding

The study was funded by the National Health and Medical Research Council of Australia (NHMRC, grant ID: 455592 and 455593). Dr Vanessa Murphy is the recipient of a NHMRC Career Development Fellowship (grant ID 1084816) and the Gladys M Brawn Memorial Career Development Fellowship from University of Newcastle. Prof Peter Gibson is a NHRMC Practitioner Fellow (grant ID 1155810).