Inhaled steroids preferred over cromolyn to treat asthma

Adults and children with asthma will breathe deeper and have better control over their asthma with inhaled corticosteroids than with the medicine cromolyn, according to a new review of recent studies comparing the two treatments.

Adult asthma patients using inhaled steroids such as the brand names Beclovent, Pulmicort and Flovent had on average three fewer severe asthma flare-ups each year compared to patients using inhaled cromolyn, sold under the brand name Intal.

Patients taking the steroids also scored significantly higher on tests of lung function and used their “rescue” inhalers less often than those taking cromolyn, say James Guevara, M.D., of the University of Pennsylvania School of Medicine and colleagues.

The findings were similar for children, Guevara and colleagues add, saying that their review supports recent consensus in the medical community that favors inhaled corticosteroids as a first-choice treatment for asthma.

“To our knowledge, this is the first systematic review comparing the effects of cromolyn to the gold standard, inhaled steroids,” Guevara said.

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The consensus still leaves room for cromolyn treatment, according to William Storms, M.D., an allergist at the University of Colorado Health Sciences Center and director of the William Storms Allergy Clinic in Colorado Springs.

“Any expert would agree that inhaled corticosteroids are preferred first-line therapy for treatment of persistent asthma, which requires daily therapy. But we also will agree with the NIH [National Institutes of Health] asthma guidelines, which state that cromolyn and other drugs are alternative therapies,” Storms said.

Cromolyn, or sodium cromoglycate, and inhaled corticosteroids both block the action of certain inflammatory cells in the lungs. Physicians recommend both types of medication for persistent asthma, but individual studies disagree about which type of medication works best, the reviewers found.

“The safety of sodium cromoglycate has been well established, but the effectiveness of sodium cromoglycate in controlling asthma symptoms may be limited,” Guevara said, adding that the lack of effective control might be one reason cromolyn has fallen out of favor compared to inhaled corticosteroids since the 1990s.

Cromolyn’s manufacturer has changed several times during the past two decades, which may also explain why the drug’s popularity has waned, Storms said. The succession of companies “did not spend one dollar in research in the past 20 years to study cromolyn. All of the data are old and most are forgotten,” he said.

The Cochrane reviewers examined 17 studies involving 1279 children and eight studies involving 321 adults with asthma. They found no differences in serious side effects between those using the steroids and those using cromolyn, but acknowledge that adverse effects were reported inconsistently.

Guevara and colleagues conclude that inhaled corticosteroids were superior to cromolyn regardless of the severity of the asthma. They suggest the results are so decisive that future studies comparing the two types of drugs “may not be warranted.”

Storms said some patients may still prefer to stay away from inhaled corticosteroids.

“We need to examine the total patient and treat the patient, not the disease. When I tell patients I am suggesting they take an ICS [inhaled corticosteroid], many of them get that wide-eyed gaze because of the word ’steroid.’ Then I discuss the fact that ICS are inhaled and not systemic but many patients would still prefer to try something else, if possible. That something else could be cromolyn,” he says.