Inhaled fluticasone versus inhaled beclomethasone or inhaled budesonide for chronic asthma

BACKGROUND

Beclomethasone dipropionate (BDP) and budesonide (BUD) are commonly prescribed inhaled corticosteroids for the treatment of asthma, Fluticasone propionate (FP) is newer agent with greater potency in in-vitro assays.

OBJECTIVES

To compare the efficacy and safety of Fluticasone to Beclomethasone or Budesonide in the treatment of chronic asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group trial register (January 2003) and reference lists of articles. We contacted trialists and pharmaceutical companies for additional studies and searched abstracts of major respiratory society meetings (1997 to 2003).

SELECTION CRITERIA

Randomised trials in children and adults comparing Fluticasone to either Beclomethasone or Budesonide in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data. Quantitative analyses were undertaken using RevMan analyses 1.0.1.

MAIN RESULTS

48 studies (11,479 participants) met the inclusion criteria. Methodological quality was variable. When compared at a FP:BUD/BDP dose ratio of 1:2, fluticasone produced a significantly greater FEV1 (Weighted Mean Difference (WMD) 0.11 litres, 95% Confidence Interval (CI) 0.01 to 0.20 litres), morning PEF (WMD 13 L/min, 95%CI 5 to 22 L/min) and evening PEF (WMD 11 L/min, 95%CI 1 to 20 L/min). This applied to all drug doses, age groups, and delivery devices, although subgroup analyses suggested that the relative benefit of FP may be greater in more severe patients treated with higher doses of inhaled corticosteroid. No difference between fluticasone and beclomethasone or budesonide were seen for trial withdrawals (Peto OR 0.76, 95%CI 0.53 to 1.09). Symptoms and rescue medication use were widely reported but few trials provided sufficient data for analysis. A higher likelihood of pharyngitis (Peto Odds Ratio 2.16; 95% CI 1.43 to 3.24) was apparent when patients were treated with fluticasone at twice the dose of BDP/BUD, although there was unexplained heterogeneity in this effect between trials. There was no difference in the likelihood of oral Candidiasis. Plasma cortisol and 24 hour urinary cortisol were measured frequently but data presentation was limited.

REVIEWERS' CONCLUSIONS

Fluticasone given at half the daily dose of beclomethasone or budesonide leads to small improvements in measures of airway calibre, but it appears to have a higher risk of causing side-effects when given at the same daily dose.

Identification of psychological morbidity in older people in primary care by practice nurses

Older people with psychological morbidity generally first present to health services in primary care, where they are increasingly seen by primary care nurses. In order to evaluate primary care nurses' identification of psychological morbidity, 190 older patients attending eight practice nurses completed the General Health Questionnaire (GHQ) and the practice nurses made an assessment as to the presence or absence of psychological problems. The practice nurses identified only 26% of probable cases of psychological morbidity identified by the GHQ. Their threshold for identification was high, rating only 12% of patients as experiencing psychological problems compared to 29% probable cases identified by the GHQ, and their accuracy was low (kappa for agreement between GHQ and nurse ratings = 0.23). Likelihood of identification depended on length and type of visit. The findings suggest that it may be unrealistic to expect practice nurses, without additional training and reorganisation of their work, to identify more than a minority of older patients with psychological morbidity in the course of their routine work.

Development of multiplexed nucleic acid testing for human immunodeficiency virus type 1 and hepatitis C virus

BACKGROUND AND OBJECTIVES

In most Western countries, blood donations are routinely screened for hepatitis C virus (HCV) RNA by polymerase chain reaction (PCR) or other nucleic acid tests. We describe the development of a multiplexed assay for human immunodeficiency virus type 1 (HIV-1) and HCV in an internally controlled PCR suitable for large-scale blood donor screening.

MATERIALS AND METHODS

The HIV/HCV multiplexed PCR used primers from highly conserved regions in the long terminal repeat region. The National Institute for Biological Standards and Controls (NIBSC) International HIV-1 RNA standard, run control and HIV-1 subtype panel were used for assay evaluation.

RESULTS

The HIV-1 PCR showed a sensitivity of 24 IU/ml for HIV-1 RNA (a dilution where 95% of replicate reactions were positive), which was at least five times more sensitive than the Roche Monitor version 1.5 (using the ultrasensitive extraction protocol) and Organon NASBA assays. The assay was capable of detecting all subtypes of HIV-1 (A to H), as well as the more divergent group N and O variants. The sensitivity of the PCR was unaffected by multiplexing with HCV primers and by the presence of a bovine viral diarrhoea virus (BVDV) internal control.

CONCLUSION

We have developed a highly sensitive multiplexed PCR for HIV-1 and HCV RNA screening that can be introduced into current PCR-based blood donor screening at minimal cost and without significant operational changes.

Fluticasone versus beclomethasone or budesonide for chronic asthma

BACKGROUND

Beclomethasone dipropionate (BDP) and budesonide (BUD) are commonly prescribed inhaled corticosteroids for the treatment of asthma, Fluticasone propionate (FP) is newer agent with greater potency in in-vitro assays.

OBJECTIVES

To compare the efficacy and safety of Fluticasone to Beclomethasone or Budesonide in the treatment of chronic asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trial Register (1999) and reference lists of articles. We contacted trialists and pharmaceutical companies for additional studies and searched abstracts of major respiratory society meetings (1997-1999).

SELECTION CRITERIA

Randomised trials in children and adults comparing Fluticasone to either Beclomethasone or Budesonide in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data. Quantitative analyses where undertaken using Review Manager 4.0.3 with Metaview 3.1.

MAIN RESULTS

42 studies (>10,000 patients) met the inclusion criteria. Methodological quality was variable. When compared at a FP:BUD/BDP dose ratio of 1:2, fluticasone produced a significantly greater FEV1 (Weighted Mean Difference (WMD) 0.11 litres, 95% Confidence Interval (CI) 0.01, 0.20 litres), morning PEF (WMD 13 L/min, 95%CI 5, 22 L/min) and evening PEF (WMD 11 L/min, 95%CI 1, 20 L/min). This applied to all drug doses, age groups, and delivery devices, although subgroup analyses suggested that the relative benefit of FP may be greater in more severe patients treated with higher doses of inhaled corticosteroid. No difference between fluticasone and beclomethasone or budesonide were seen for trial withdrawals (Peto OR 0.77, 95%CI 0.54, 1.10). Symptoms and rescue medication use were widely reported but few trials provided sufficient data for analysis. A higher likelihood of pharyngitis (Peto Odds Ratio 2.16; 95% CI 1.42, 3.28) was apparent when patients were treated with fluticasone at twice the dose of BDP/BUD, although was unexplained heterogeneity in this effect between trials. There was no difference in the likelihood of oral Candidiasis. Plasma cortisol and 24 hour urinary cortisol were measured frequently but data presentation was limited.

REVIEWER'S CONCLUSIONS

Fluticasone given at half the daily dose of beclomethasone or budesonide leads to small improvements in measures of airway calibre, but it appears to have a higher risk of causing side-effects when given at the same daily dose.

Inhaled fluticasone at different doses for chronic asthma

BACKGROUND

Inhaled fluticasone propionate (FP) is a high potency inhaled corticosteroid used in the treatment of asthma.

OBJECTIVES

1. To assess the efficacy and safety outcomes in studies that compared inhaled fluticasone at different nominal daily doses in the treatment of chronic asthma. 2. To test for the presence of a dose response effect.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trial Register (1999) and reference lists of articles. We contacted trialists and pharmaceutical companies for additional studies and searched abstracts of major respiratory society meetings (1997-1999).

SELECTION CRITERIA

Randomised trials in children and adults comparing fluticasone at different nominal daily doses in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data. Quantitative analyses where undertaken using Review Manager 4.0.3 with Metaview 3.1.

MAIN RESULTS

20 studies (>6000 patients) met the inclusion criteria. Methodological quality was high. In non-oral steroid treated asthmatics with mild-moderate disease, a dose response effect was present for morning PEF; when comparing low doses (200 vs 100 mcg/d) Weighted Mean Difference (WMD) 6 L/min, 95% Confidence Interval (CI) 1, 10 L/min; medium-low dose (400-500 vs 100 mcg/d), WMD 8 L/min, 95%CI 1,15 L/min); and high vs low dose (800-1000 vs 50-100 mcg/d), WMD 22 L/min 95% CI 15,29 L/min). There was no dose response in symptoms or rescue beta2 agonist use. Hoarseness and oral Candidiasis was significantly higher with 800-1000 mcg/d than 50-100 mcg/d. In oral steroid dependent disease gain 2000 mcg/d had a greater effect than 1000-1500 mcg/d in likelihood of stopping prednisolone (Peto Odds Ratio 2.8, 95% CI 1.3, 6.3) and reduced daily prednisolone dose (WMD 2.0 mg/d, 95% CI 0.1, 4.0 mg/d).

REVIEWER'S CONCLUSIONS

Effects of fluticasone are dose dependent but relatively small. Patients with mild to moderate disease achieve similar levels of asthma control on low doses of fluticasone (200 mcg/d or less) as they do on high doses (500 mcg/d or greater). In oral corticosteroid dependent asthmatics, reductions in prednisolone requirement may be gained with FP 2000 mcg/d.

Inhaled beclomethasone versus budesonide for chronic asthma

BACKGROUND

Beclomethasone dipropionate (BDP) and budesonide (BUD) are used widely in the treatment of chronic asthma. The two drugs have different in vitro pharmacokinetic characteristics. It is unclear whether this translates into clinically significant differences in efficacy or safety when treating children and adults with chronic asthma.

OBJECTIVES

To assess clinical outcomes in studies which have compared inhaled BDP and BUD in the treatment of chronic asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trial Register (1999) and reference lists of articles. We contacted trialists and pharmaceutical companies for additional studies and searched abstracts of major respiratory society meetings (1997-1999).

SELECTION CRITERIA

Prospective, randomised trials comparing BDP to BUD in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data; authors were contacted to clarify missing information. Quantitative analyses where undertaken using Review Manager 4.0.3 with Metaview 3.1.

MAIN RESULTS

24 studies met the criteria for inclusion (1174 subjects). Methodological quality was variable. A meta-analysis of crossover studies did not demonstrate a significant difference between BDP and BUD for FEV1, morning PEF, evening PEF, asthma symptoms or rescue beta2 agonist use, over a dose range of 400 to 1000 mcg/d. The majority of crossover trials had significant design flaws related to a lack of washout and/or failure to exclude carryover effects so the results must be viewed with caution. A single crossover study with adequate washout showed that BUD 400 mcg/d delivered via Turbohaler dry powder inhaler (DPI) may be more effective than BDP 400 mcg/d delivered via Rotahaler DPI in reducing histamine bronchial hyper-responsiveness: Weighted Mean Difference (WMD) 0.43 log10 PC20 FEV1 (95% Confidence Intervals (CI) 0.05, 0.81 log10 PC20 FEV1). A meta-analysis of two parallel group, dose down-titration studies (231 patients) showed that less BUD delivered via a Turbohaler DPI was required to maintain control in adults asthmatics compared to BDP delivered via metered dose inhaler with or without a spacer: WMD 444 mcg/d (95% CI 332, 556 mcg/d).

REVIEWER'S CONCLUSIONS

There is limited high quality randomised controlled trial data comparing the relative efficacy of BDP and BUD. Current guidelines (BTS 1997, GINA 1995, NHLBI 1997) assume BDP and BUD to have equal efficacy, such that for each defined level of asthma severity, the recommended doses BDP and BUD are the same. Although there is some data to suggest that BUD via Turbohaler is more effective than BDP via either Rotahaler or MDI (with and without spacer), these comparisons are confounded by use of different delivery devices, and are not sufficient to warrant a change in guideline recommendations.

Time of feeding and possible associated thermoregulatory benefits in bronze mannikins Lonchura cucullata

Birds with a small body size have a high surface area to volume ratio, and this means that they have a high rate of heat loss to the environment. Birds may employ behavioural strategies in order to counter this heat loss. The adjustment of feeding patterns in the short term is probably the least documented of all of these strategies. Feeding results in the specific dynamic effect (SDE) which increases the metabolic rate of animals after a feeding bout. This increase in metabolic rate has been reported to possibly substitute for thermoregulatory costs in a variety of endotherms, including house wrens (Troglodytes aedon) and a variety of finch species. The thermoneutral zone was described for bronze mannikins, Lonchura cucullata (T(lc)=33.7 degrees C), and the bronze mannikins' post-absorptive physiology was described within this thermoneutral zone. Bronze mannikin mean basal metabolic rate (0.043+/-0.0038 S.E. ml O(2) min(-1) g(-1)), daytime resting metabolic rates (0.0549+/-0.0088 S.E. ml O(2) min(-1) g(-1)), and diurnal metabolic responses were described. The SDE in bronze mannikins was demonstrated within the thermoneutral zone, and was quantified. The mean magnitude of the SDE was 26.42% of mean total metabolism of post-absorptive birds. The magnitude of this SDE was independent of meal size and bird body mass. Assuming a 100% substitution, the presence of the SDE may afford bronze mannikins a maximum thermoregulatory energy saving of approximately 71.76 J g(-1) over a 300-min period.

Pain management 2: the use of pyschological approaches to pain

This article is the second of a two-part series looking at the psychological and social factors which affect pain perception. The first article (Vol 10(14): 903-11) examined neurophysiological and psychological factors of pain perception. This article considers the importance of the nurse-patient interaction in the management of patients' pain. It outlines the adoption of several psychological approaches which could be utilized by nurses when dealing with patients in pain. The need to encourage a feeling of control over pain is discussed in relation to the use of patient-controlled analgesia and the development of positive coping skills. The value of good communication skills is emphasized as being essential in encouraging patients in pain to utilize these psychological approaches.

Pain management 1: psychological and social aspects of pain

This two-part article presents psychological and social factors which affect pain perception and response and the implications of these for nursing practice. In this article, the complex interactions between neurophysiological and psychological factors are outlined and theories of pain perception and ways in which the pain experience can be modulated are presented. The role of psychological factors, attitudes, beliefs and expectations of both patient and practitioner, pain behaviours and ability to cope are discussed. In the second part, these are further elaborated with particular reference to the nurse-patient interaction. The use of psychological approaches to augment clinical practice, such as education, reduction of anxiety and improving coping ability, are suggested. Finally, the importance of communication skills in pain management is addressed.

Relation of measures of sleep-disordered breathing to neuropsychological functioning

Sleep-disordered breathing (SDB) has been associated with neuropsychological (NP) deficits. The extent to which such effects are attributable to unmeasured confounders or selection biases, or are manifest across a range of SDB is unclear. The relationship of SDB with a broad range of NP functions was examined in 100 volunteers with a spectrum of SDB and without underlying comorbidity. Factor analysis suggested that the NP tests could be summarized as four constructs: declarative memory, signal discrimination, working memory, and set shifting. These factors plus vigilance were dependent variables. Independent variables were age, the respiratory disturbance index (RDI), a sleepiness score, the arousal index, and sleep-associated hypoxemia. Factors "declarative memory" (measuring 25% of the common variance, alpha = 0.95), "signal discrimination" (10% variance, alpha = 0.70), and "working memory" (9% variance, alpha = 0.52) were each significantly, linearly predicted by hypoxemia and/or the RDI, with no evidence for significant threshold effects. SDB measures accounted for 4-6% of the variance in NP constructs. In contrast, sleepiness best predicted vigilance. Thus, adverse exposures (hypoxemia or RDI) during sleep may negatively influence NP functions in a dose-response relationship, and, other than vigilance, these effects may not be directly attributable to sleepiness.

Elliptic flow in Au+Au collisions at square root(S)NN = 130 GeV

Elliptic flow from nuclear collisions is a hadronic observable sensitive to the early stages of system evolution. We report first results on elliptic flow of charged particles at midrapidity in Au+Au collisions at square root(S)NN = 130 GeV using the STAR Time Projection Chamber at the Relativistic Heavy Ion Collider. The elliptic flow signal, v2, averaged over transverse momentum, reaches values of about 6% for relatively peripheral collisions and decreases for the more central collisions. This can be interpreted as the observation of a higher degree of thermalization than at lower collision energies. Pseudorapidity and transverse momentum dependence of elliptic flow are also presented.

Beclomethasone at different doses for chronic asthma (review)

BACKGROUND

Beclomethasone dipropionate (BDP) is available in a wide range of daily doses for the treatment of long-term asthma.

OBJECTIVES

To assess the evidence for a dose response relationship for BDP in the treatment of long-term asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group trial register, Cochrane Controlled Trials Register (The Cochrane Library issue 1 1999) and references lists of articles. Authors and Glaxo Wellcome UK were contacted to identify eligible studies. We also hand searched the proceeding from relevant respiratory society meetings, the British Journal of Clinical Research and the European Journal of Clinical Research for studies.

SELECTION CRITERIA

Prospective, randomised trials comparing two or more daily doses of BDP in patients over the age of two years with long-term asthma.

DATA COLLECTION AND ANALYSIS

Trials were selected for inclusion and scored for quality by two reviewers. Data were extracted by one reviewer. Authors were contacted to clarify details of study design and retrieve missing data.

MAIN RESULTS

11 trials involving 1614 subjects were included. Methodological quality was variable. Studies rarely gave a clear indication of the degree of asthma control at baseline. Less than two-fold to five-fold dose differences were assessed by different studies. The results are reported as weighted mean differences (WMD) with 95% confidence limits (95% CI). The number of trials (N) contributing to each outcome is stated. In non-oral steroid treated asthmatics a small advantage of BDP 800 mcg/d over 400 mcg/d was apparent for improvement in morning peak expiratory flow rate (PEFR) compared to baseline, WMD 11 L/min (95% CI 4 to 19 L/min) N=2; improvement in forced expired volume in one second (FEV1) compared to baseline, WMD 9 ml (95% CI 3 to 140) N=1; and reduction in night-time symptom score compared to baseline, WMD 0.13 (95% CI 0.04 to 0.22) N=1. Studies that assessed BDP 1000 v 500 mcg/d and BDP 1600 v 400 mcg/d demonstrated significant advantage of higher dose over lower dose for histamine bronchial hyper-responsiveness (BHR) and percentage improvement in FEV1 compared to baseline. No differences between higher and lower daily doses of BDP were apparent for daytime symptoms, withdrawals due to asthma exacerbation, oropharyngeal side effects or measures of hypothalamo-pituitary-adrenal (HPA) function. No difference in prednisolone sparing effect was apparent when comparing high dose and low dose BDP in oral corticosteroid (OCS) dependent patients.

REVIEWER'S CONCLUSIONS

BDP appears to demonstrate a shallow dose response effect in long-term asthma for a small number of efficacy outcomes over range of daily doses from 400 mcg/d to 1600 mcg/d, although the clinical significance of the improvements afforded by higher doses is questionable.

Holding chambers versus nebulisers for inhaled steroids in chronic asthma

BACKGROUND

Inhaled corticosteroids are available in the form of a suspension for nebulisation, although the role of this mode of therapy in the treatment of chronic asthma is still unclear.

OBJECTIVES

To assess the efficacy and safety of inhaled corticosteroids delivered via nebuliser versus holding chamber for the treatment of chronic asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trial Register (1999) and reference lists of articles. We contacted the authors of studies and pharmaceutical companies for additional studies and hand-searched the British Journal of Clinical Research, European Journal of Clinical Research and major respiratory society meeting abstracts (1997-1999).

SELECTION CRITERIA

Randomised controlled trials comparing nebuliser to holding chamber in the delivery of inhaled corticosteroids for the treatment of chronic asthma. All age groups of patients were considered. Two reviewers assessed articles for inclusion; two reviewers independently assessed included studies for methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data; authors were contacted to clarify missing information. Quantitative analyses were undertaken using Review Manager 4.1 with MetaView 3.1.

MAIN RESULTS

Two studies were selected for inclusion (63 subjects), both concerned adults. Methodological quality was variable. Due to design differences it was not appropriate to pool the studies. The single high quality study compared budesonide 2000-8000 mcg delivered via Pari Inhalier Boy jet nebuliser with inspiration-only inhalation to budesonide 1600 mcg via large volume spacer. The nebuliser delivery led to higher morning peak expiratory flow values (25 L/min p<0.01), higher evening values (30L/min, p<0.01), lower rescue beta2 agonist use and symptom scores compared to the holding chamber delivery.

REVIEWER'S CONCLUSIONS

Budesonide in high dose delivered by the particular nebuliser used in the only double-blinded study that could be included in this review was more effective than budesonide 1600 mcg via a large volume spacer. However, it is not clear whether this was an effect of nominal dose delivered or delivery system. Cost, compliance and patient preference are important determinants of clinical effectiveness that have not been assessed. Future studies are needed to evaluate the relative effectiveness of inhaled corticosteroids delivered by different combinations of nebuliser/compressor compared to holding chamber. Moreover, further studies assessing these delivery methods are needed in infants and pre-school children, as these are groups that are likely to be considered for treatment with nebulised corticosteroids.

Budesonide at different doses for chronic asthma

BACKGROUND

Inhaled budesonide (BUD) is available in a range of doses for treating chronic asthma.

OBJECTIVES

To quantitatively assess the efficacy and safety of budesonide at different doses in order to establish whether a clinically significant dose response profile exists.

SEARCH STRATEGY

A search was carried out for Controlled and Randomised Clinical Trials (RCTs) using the Cochrane Airways Group trial register, correspondence with trial authors and the manufacturer.

SELECTION CRITERIA

Randomised trials in children and adults comparing one dose of budesonide to a second dose in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data; authors were contacted to clarify missing information. Quantitative analyses where undertaken using Review Manager.

MAIN RESULTS

24 studies were selected for inclusion in the review (3907 subjects). In non-oral steroid treated, mild to moderately severe asthma no clinically worthwhile differences in FEV1, morning PEFR, symptom scores or rescue beta2 agonist use were apparent across a dose range of 200-1600 mcg/d. However, in moderate to severe asthma there was a significant reduction in the likelihood of trial withdrawal due to asthma exacerbation with BUD 800 mcg/d compared to 200 mcg/d: RR 3.93 (95% CI, 1.4 to 10.9). This result was largely weighted by a single large high quality RCT. In a single study in patients receiving oral corticosteroids, clinically significant improvements favouring high dose BUD (1600 mcg/d) over low dose (200 mcg/d) were apparent for FEV1 and morning PEFR. In two studies there was no dose dependent oral steroid sparing effect for BUD 1600 mcg/d v 800 or 400 mcg/d. Statistically significant, dose dependent suppression of 24 hour urinary free cortisol excretion and serum cortisol post synthetic ACTH infusion over the dose range 800-3200 mcg/d were apparent but the clinical significance of these findings is unclear.

REVIEWER'S CONCLUSIONS

Budesonide exhibits a clinically significant dose response effect for improvement in FEV1 in severe asthma and reduction of exacerbations in moderate to severe asthma. No significant dose dependent improvements in FEV1, PEFR or symptoms are evident in non-oral steroid treated asthmatics with mild to moderate disease. Dose dependent alterations in sensitive measures of hypothalamic-pituitary-adrenal function were evident but the clinical significance of these changes is unclear.

Inhaled fluticasone propionate for chronic asthma

BACKGROUND

Inhaled fluticasone propionate (FP) is a relatively new inhaled corticosteroid for the treatment of asthma.

OBJECTIVES

1. To assess efficacy and safety outcomes in studies that compared FP to placebo for treatment of chronic asthma. 2. To explore the presence of a dose-response effect.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trial Register (1999), reference lists of articles, contacted trialists and searched abstracts of major respiratory society meetings (1997-1999).

SELECTION CRITERIA

Randomised trials in children and adults comparing FP to placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data. Quantitative analyses where undertaken using Review Manager 4.0.3 with MetaView 3.1.

MAIN RESULTS

28 studies were selected for inclusion (5788 subjects). Methodological quality was high. In non-oral steroid treated asthmatics with mild-moderate disease FP produced improvements from baseline compared to placebo: FEV1 Weighted Mean Difference (WMD) 0.31 litres (95% confidence interval (CI) 0.27 to 0.36 litres); morning PEF WMD 29 /min (95% CI 24 to 33 L/min); symptom scores Standardised Mean Difference (SMD) 0.59 (95% CI 0.47 to 0.71); reduction in rescue beta2 agonist use WMD 1.1 puffs/d (95% CI 0.9 to 1.4). Similar effects were seen for all doses up to 1000 mcg/d. A shallow dose response effect was apparent: eg change in morning PEF with FP 1000 mcg/d WMD 49 L/min (95% CI 41 to 58 L/min). High dose FP reduced the number of patients dependent on prednisolone: FP 1000-1500 mcg/d Peto Odds Ratio 0.07 (95% CI 0.05 to 0.10). FP at all doses led to a greater likelihood of sore throat, hoarseness and oral Candidiasis.

REVIEWER'S CONCLUSIONS

Doses of FP in the range 100-1000 mcg/d are effective. Although there appears to be a dose-response effect, in most patients with mild-moderate asthma improvements with low dose FP are only a little less than those with high doses. High dose FP appears to have worthwhile oral-corticosteroid reducing properties. FP use is accompanied by an increased likelihood of oropharyngeal side effects and this appears to be dose dependent.

Budesonide for chronic asthma in children and adults

BACKGROUND

Inhaled budesonide is a widely used inhaled corticosteroid for asthma.

OBJECTIVES

The objectives of this review was to compare the efficacy of budesonide with placebo in the treatment of chronic asthma.

SEARCH STRATEGY

The Cochrane Airways Group Trial Register and reference lists of articles was searched. We contacted trialists for additional studies and searched abstracts of major respiratory society meetings (1997-1999).

SELECTION CRITERIA

Randomised trials in children and adults comparing budesonide to placebo in the treatment of chronic asthma.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed articles for inclusion and methodological quality. One reviewer extracted data.

MAIN RESULTS

43 studies met the inclusion criteria (2801 subjects). In non-oral steroid treated asthmatics, budesonide led to significant improvements in a number of measures of airway function. These included FEV1, Weighted Mean Difference (WMD) 3.7% predicted (95% CI 0.1, 7.2%); improvement in morning peak flow (PEF) from baseline WMD 29 L/min (95% CI 22, 36 L/min); improvement in evening PEF from baseline WMD 21 L/min (95% CI 13, 29 L/min). Varying methods of reporting symptoms limited the pooling of studies but all high methodological quality studies demonstrated significant improvements compared to placebo. Health status was not reported. Risk of trial withdrawal due to asthma exacerbation was lower with budesonide compared to placebo, relative risk 0.17 (95% CI 0.09, 0.33). Doses of 500-800 mcg/d appeared to have slightly larger effect sizes than lower doses, but no advantage for high doses were apparent. A single high quality RCT reported significant reductions in daily prednisolone requirement and the number of patients able to discontinue prednisolone completely in budesonide treated subjects compared to placebo. No difference in risk of oropharyngeal soreness/hoarseness or oral Candidiasis was apparent for budesonide compared to placebo. Long-term risk of adrenal insufficiency was not reported.

REVIEWER'S CONCLUSIONS

This review strongly supports use of budesonide in chronic asthma. Consensus guidelines for chronic asthma suggest titrating inhaled steroid dose to individual requirements. Evidence from this review of trials does not present a case for routine dose titration above 800 mcg/d.

Effects of ingesting a large volume of carbohydrate-electrolyte solution on rehydration during recovery and subsequent exercise capacity

This randomized, double-blind study examined the effects of rehydration per se and rehydration plus carbohydrate (CHO) ingestion during recovery (REC) on subsequent endurance running capacity. Nine men ran at 70% VáO2max on a level treadmill for 90 min (T1) on two occasions, followed by a 4 hour REC and a further exhaustive run at the same speed (T2). During the first 3 hours of REC, subjects drank either a 6.9% CHO-electrolyte solution (CE) or a CHO- and electrolyte-free sweetened placebo (PL) every 30 min. Volumes prescribed were 200% of the fluid lost after T1, but the actual volume of fluid ingested during the REC ranged from 113-200% and 88. 5-200% of the body mass lost for the CE and PL trials (NS). However, positive fluid balance was found in both trials after REC. During T2, run time was 24.3 +/- 4.4 min longer in the CE trial (69.3 +/- 5.5 vs. 45.0 +/- 4.2 min; p <.05). Higher blood glucose concentrations were observed throughout REC in the CE trial. These results suggest that ingesting a CHO-electrolyte solution is more effective in restoring endurance capacity compared to the same large volume of placebo, even though complete rehydration was achieved in both trials.

Environmental influences on the failure to drink in inbred rats with an ethanol preference

To investigate the environmental influences on the initiation of voluntary consumption of 10% ethanol (EtOH) in rats with differing genetic susceptibility to excessive EtOH consumption, Maudsley reactive (MR/Har) and nonreactive (MNRA/Har) inbred rats were observed in different types of caging environments. Singly housed male and female rats of both strains living in Observational (O) cages drank markedly less EtOH during 3 weeks of two-bottle choice than did rats living in standard-control (C) individual cages. When male rats had a preexisting moderate or heavy pattern of EtOH intake (manipulated through prior EtOH experience), moving to the O cage did not reduce EtOH intake. To investigate the nature of the above cage effect (the reduced initiation of EtOH consumption), we compared the manner in which food had been distributed (traditional food hopper in C cages versus loose distribution in O cages) independently of cage type. The results showed that MR/Har male rats that obtained food through a hopper in both O or C cages drank significantly more EtOH than rats that had food loosely distributed in the O or C cages. The results suggest that differences in the mode of food procurement and caging can play a large role in whether the phenotype for excessive EtOH intake is expressed in the acquisition of an EtOH preference in genetically vulnerable rats.

Physical and other non-pharmacological interventions for fibromyalgia

There is little empirical evidence for the effectiveness of physical and other non-pharmacological approaches to the management of fibromyalgia. Although a number of studies have been conducted into such approaches, many of these are uncontrolled, and relatively few randomized controlled trials of appropriate size and methodological rigour have been carried out. This chapter provides an overview of the evidence available under the following headings: exercise, EMG biofeedback training, electrotherapy and acupuncture, patient education and self-management programmes, multimodal treatment approaches, and other interventions. It is hard to reach firm conclusions from the literature, owing to the variety of interventions that have been evaluated and the varying methodological quality of the studies concerned. Nonetheless, in terms of specific interventions, exercise therapy has received a moderate degree of support from the literature, and has been subjected to more randomized studies than any other intervention. In contrast, there is little or no evidence available for most types of electrotherapy. In terms of overall management strategies, a multimodal programme of management, including physical, psychological and educational components and delivered in a multidisciplinary setting, has gained some support from descriptive and experimental studies, and accords with current understanding of the aetiology and clinical features of fibromyalgia. There is a clear need for further systematic evaluation of the effectiveness of non-pharmacological treatment approaches in fibromyalgia.