Treating Mild Asthma

By Adem Lewis / in , , , , , , /

This is Jeffrey Drazen for the New England Journal of Medicine. Approximately half of patients with asthma have “mild disease”. Of these patients, some are treated with short acting beta-agonists, which we call SABAs, only when they have asthma symptoms, while others are treated with inhaled glucocorticoids, which we call ICS, every day without regard to asthma symptoms. Is there another approach to treatment of
these patients? The SYGMA 1 trial was designed to compare the number of well controlled asthma weeks, a composite measure of asthma burden, among various regimens used to treat mild asthma. The trial enrolled just under 4,000 patients with mild asthma who were randomized to one of 3 inhaled treatment arms: twice-daily placebo plus as-needed SABA which we call “as-needed SABA”, twice-daily placebo plus as-needed ICS and a long-acting beta-agonist in a single inhaler, which we call “as-needed combination”; or twice-daily ICS plus an as-needed SABA, which we call “ICS maintenance”. After a year of treatment, the percentage
of well-controlled asthma weeks, was 34.4% for “as-needed combination” as compared
with 31.1% for “as-needed SABA” and 44.4% for “ICS maintenance”. “ The “as-needed combination’ was superior to “as-needed SABA”, but inferior to “ICS maintenance”. The rate of severe exacerbations was 0.07 per year with “as-needed combination” as compared with 0.09 per year with “ICS
maintenance” and 0.20 per year with “as-needed SABA”. Patients on “as-needed combination” used only 1/5 of the median dose of inhaled glucocorticoids as “ICS maintenance.” ICS maintenance gives better asthma control, but is no better at preventing severe exacerbations than “as-needed combination”, which has
less ICS exposure. Full study results are available at

One thought on “Treating Mild Asthma

  1. This study is misleading. The SABA was nonstandard for clinical practice (terbutiline rather than albuterol), also the ICS maint group used BID dosing when for mild asthma daily dosing is typically adequate. So, the difference in daily median use would have been closer to 1/2 than 1/5 if once daily dosing had been used in the ICS "control" group.
    Still interesting, and food for thought. But would be surprised if this study was not funded, at least in part, by a drug company with interest in selling the LABA/steroid inhaler.

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