• William J Calhoun, Bill T Ameredes, Tonya S King, Nikolina Icitovic, Eugene R Bleecker, Mario Castro, Reuben M Cherniack, Vernon M Chinchilli, Timothy Craig, Loren Denlinger, Emily A DiMango, Linda L Engle, John V Fahy, J Andrew Grant, Elliot Israel, Nizar Jarjour, Shamsah D Kazani, Monica Kraft, Susan J Kunselman, Stephen C Lazarus, Robert F Lemanske, Njira Lugogo, Richard J Martin, Deborah A Meyers, Wendy C Moore, Rodolfo Pascual, Stephen P Peters, Joe Ramsdell, Christine A Sorkness, E Rand Sutherland, Stanley J Szefler, Stephen I Wasserman, Michael J Walter, Michael E Wechsler, Homer A Boushey, and Asthma Clinical Research Network of the National Heart, Lung, and Blood Institute.
• Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA. william.calhoun@utmb.edu
• JAMA. 2012 Sep 12;308(10):987-97.

ContextNo consensus exists for adjusting inhaled corticosteroid therapy in patients with asthma. Approaches include adjustment at outpatient visits guided by physician assessment of asthma control (symptoms, rescue therapy, pulmonary function), based on exhaled nitric oxide, or on a day-to-day basis guided by symptoms.ObjectiveTo determine if adjustment of inhaled corticosteroid therapy based on exhaled nitric oxide or day-to-day symptoms is superior to guideline-informed, physician assessment-based adjustment in preventing treatment failure in adults with mild to moderate asthma.Design, Setting, And ParticipantsA randomized, parallel, 3-group, placebo-controlled, multiply-blinded trial of 342 adults with mild to moderate asthma controlled by low-dose inhaled corticosteroid therapy (n = 114 assigned to physician assessment-based adjustment [101 completed], n = 115 to biomarker-based [exhaled nitric oxide] adjustment [92 completed], and n = 113 to symptom-based adjustment [97 completed]), the Best Adjustment Strategy for Asthma in the Long Term (BASALT) trial was conducted by the Asthma Clinical Research Network at 10 academic medical centers in the United States for 9 months between June 2007 and July 2010.InterventionsFor physician assessment-based adjustment and biomarker-based (exhaled nitric oxide) adjustment, the dose of inhaled corticosteroids was adjusted every 6 weeks; for symptom-based adjustment, inhaled corticosteroids were taken with each albuterol rescue use.Main Outcome MeasureThe primary outcome was time to treatment failure.ResultsThere were no significant differences in time to treatment failure. The 9-month Kaplan-Meier failure rates were 22% (97.5% CI, 14%-33%; 24 events) for physician assessment-based adjustment, 20% (97.5% CI, 13%-30%; 21 events) for biomarker-based adjustment, and 15% (97.5% CI, 9%-25%; 16 events) for symptom-based adjustment. The hazard ratio for physician assessment-based adjustment vs biomarker-based adjustment was 1.2 (97.5% CI, 0.6-2.3). The hazard ratio for physician assessment-based adjustment vs symptom-based adjustment was 1.6 (97.5% CI, 0.8-3.3).ConclusionAmong adults with mild to moderate persistent asthma controlled with low-dose inhaled corticosteroid therapy, the use of either biomarker-based or symptom-based adjustment of inhaled corticosteroids was not superior to physician assessment-based adjustment of inhaled corticosteroids in time to treatment failure.Trial Registrationclinicaltrials.gov Identifier: NCT00495157.

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