• Robert S Zeiger, David Mauger, Leonard B Bacharier, Theresa W Guilbert, Fernando D Martinez, Robert F Lemanske, Robert C Strunk, Ronina Covar, Stanley J Szefler, Susan Boehmer, Daniel J Jackson, Christine A Sorkness, James E Gern, H William Kelly, Noah J Friedman, Michael H Mellon, Michael Schatz, Wayne J Morgan, Vernon M Chinchilli, Hengameh H Raissy, Elizabeth Bade, Jonathan Malka-Rais, Avraham Beigelman, Lynn M Taussig, and CARE Network of the National Heart, Lung, and Blood Institute.
• Department of Allergy, Kaiser Permanente Southern California, San Diego, CA 92111, USA. robert.s.zeiger@kp.org
• N. Engl. J. Med. 2011 Nov 24; 365 (21): 199020011990-2001.

BackgroundDaily inhaled glucocorticoids are recommended for young children at risk for asthma exacerbations, as indicated by a positive value on the modified asthma predictive index (API) and an exacerbation in the preceding year, but concern remains about daily adherence and effects on growth. We compared daily therapy with intermittent therapy.MethodsWe studied 278 children between the ages of 12 and 53 months who had positive values on the modified API, recurrent wheezing episodes, and at least one exacerbation in the previous year but a low degree of impairment. Children were randomly assigned to receive a budesonide inhalation suspension for 1 year as either an intermittent high-dose regimen (1 mg twice daily for 7 days, starting early during a predefined respiratory tract illness) or a daily low-dose regimen (0.5 mg nightly) with corresponding placebos. The primary outcome was the frequency of exacerbations requiring oral glucocorticoid therapy.ResultsThe daily regimen of budesonide did not differ significantly from the intermittent regimen with respect to the frequency of exacerbations, with a rate per patient-year for the daily regimen of 0.97 (95% confidence interval [CI], 0.76 to 1.22) versus a rate of 0.95 (95% CI, 0.75 to 1.20) for the intermittent regimen (relative rate in the intermittent-regimen group, 0.99; 95% CI, 0.71 to 1.35; P=0.60). There were also no significant between-group differences in several other measures of asthma severity, including the time to the first exacerbation, or adverse events. The mean exposure to budesonide was 104 mg less with the intermittent regimen than with the daily regimen.ConclusionsA daily low-dose regimen of budesonide was not superior to an intermittent high-dose regimen in reducing asthma exacerbations. Daily administration led to greater exposure to the drug at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; MIST ClinicalTrials.gov number, NCT00675584.).

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