Step one for asthma treatment: Beta2-agonists or inhaled corticosteroids?

Inhaled corticosteroids have proven effectiveness in chronic persistent asthma and are now recommended as first-line therapy in this condition. In contrast, long term preventative therapy is not currently considered necessary for patients with disease that is only mild and episodic. Recently, there has been growing interest in the possible benefits of using inhaled corticosteroids at an earlier stage in asthma, as soon as the condition is diagnosed. The concept of early intervention is supported by the recognition that airway inflammation is common to all grades of asthma, including early and mild disease. A number of studies have suggested that delayed introduction of inhaled corticosteroids in asthma can result in a poorer clinical response. The precise reason for this is unknown, although it may result from persistent uncontrolled inflammation leading to airway remodelling associated with airflow obstruction that is relatively resistant to therapy. There have also been suggestions that early intervention may alter the natural history of the disease, either to induce sustained remission or to prevent long term decline in lung function, but these effects have yet to be clearly established. On the basis of present knowledge, early intervention remains controversial, particularly in children. The Steroid Treatment As Regular Therapy (START) trial is a large, placebo-controlled, multicentre study that is currently comparing early and delayed use of inhaled corticosteroids in adults and children with newly diagnosed asthma. It is hoped that this study will resolve some of the present uncertainties, and lead to a better understanding of whether an early intervention strategy in asthma can be justified.