• Rik J B Loymans, Armin Gemperli, Judith Cohen, Sidney M Rubinstein, Peter J Sterk, Helen K Reddel, Peter Jüni, and Gerben ter Riet.
• Department of General Practice, Academic Medical Center, University of Amsterdam, PO box 22700, 1105 DE, Amsterdam, Netherlands r.j.loijmans@amc.nl.
• BMJ. 2014 Jan 1;348:g3009.

ObjectiveTo determine the comparative effectiveness and safety of current maintenance strategies in preventing exacerbations of asthma.DesignSystematic review and network meta-analysis using Bayesian statistics.Data SourcesCochrane systematic reviews on chronic asthma, complemented by an updated search when appropriate. ELIGIBILITY CRITERIA TRIALS OF Adults with asthma randomised to maintenance treatments of at least 24 weeks duration and that reported on asthma exacerbations in full text. Low dose inhaled corticosteroid treatment was the comparator strategy. The primary effectiveness outcome was the rate of severe exacerbations. The secondary outcome was the composite of moderate or severe exacerbations. The rate of withdrawal was analysed as a safety outcome.Results64 trials with 59,622 patient years of follow-up comparing 15 strategies and placebo were included. For prevention of severe exacerbations, combined inhaled corticosteroids and long acting β agonists as maintenance and reliever treatment and combined inhaled corticosteroids and long acting β agonists in a fixed daily dose performed equally well and were ranked first for effectiveness. The rate ratios compared with low dose inhaled corticosteroids were 0.44 (95% credible interval 0.29 to 0.66) and 0.51 (0.35 to 0.77), respectively. Other combined strategies were not superior to inhaled corticosteroids and all single drug treatments were inferior to single low dose inhaled corticosteroids. Safety was best for conventional best (guideline based) practice and combined maintenance and reliever therapy.ConclusionsStrategies with combined inhaled corticosteroids and long acting β agonists are most effective and safe in preventing severe exacerbations of asthma, although some heterogeneity was observed in this network meta-analysis of full text reports.© Loymans et al 2014.

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