We present an experimental design for the evaluation of therapeutic preferences among well established similar modes of therapy. The measure of the degree of preference is based on clinical decisions to continue or discontinue the current treatment at each patient visit. Such a trial simulates decision-making in ordinary clinical practice, while adhering to the scientific principles of experimental design, and it alleviates some of the ethical problems inherent in randomized allocation of a treatment for a period of fixed length in conventional control trials. We discuss the design and methods of analysis and illustrate their application with data from a trial comparing three alternative drug treatments for chronic asthma. Such clinical trials provide a mechanism for examining concordance between the relative efficacy of treatments predicted from conventional controlled clinical trials and their ultimate performance in ordinary clinical practice, expressed in terms of therapeutic preferences.

Asthma↗

PubMedDate not supplied

Efficiency of inhaled versus oral steroid treatment of chronic asthma.

The therapeutic efficiency of oral vs. inhaled steroid treatment for chronic asthma was compared in several graded-dose, double-blind controlled trials. Inhaled steroid proved significantly more effective than alternate-morning prednisone when the two regimens were compared in the same patients at equivalent levels of systemic glucocorticoid activity. Furthermore, if given in sufficient dosage, inhaled steroids proved equally as effective as oral prednisone given daily, and better tolerated than the latter. The data support a broadening of the therapeutic role of inhaled steroid drugs to include higher dosages and patients with more severe grades of asthma. To facilitate this, concentrated formulations are needed. Until the latter become available to the practitioner, combinations of inhaled plus oral steroid treatment may be used, since these have been shown to improve the efficacy of chronic steroid therapy without worsening its adverse effects.

Administration, Inhalation↗

PubMedDate not supplied

Inhaled steroid asthma treatment: 'Primum non nocere'.

The potential risks of antiasthmatic inhaled steroid therapy are essentially dose-related and include oropharyngeal complications such as thrush and dysphonia, and systemic complications such as hyperactivity, behavioural change, hypothalamic-pituitary-adrenal axis suppression, facial and weight changes characteristic of hypercortisonism, cataracts, increased intraocular pressure, dermal atrophy causing steroid purpura, retarded growth in children and osteoporosis. A few cases of fracture or acute adrenocortical insufficiency have been reported. Because concern about these potential risks is an important impediment to the use of inhaled steroids, practical measures aimed at minimizing these risks are discussed.

Administration, Inhalation↗