title: A randomized primary care trial of steroid titration against mannitol in persistent asthma: STAMINA trial.
abstract: BACKGROUND
  We compared titrating inhaled corticosteroid (ICS) against mannitol airway hyperresponsiveness (AHR) or a reference strategy (control) based on symptoms, reliever use, and lung function in primary care.
  
  
  METHODS
  One hundred sixty-four patients with persistent asthma were randomized in parallel group fashion following an initial ICS tapering. Subsequent ICS doses (as ciclesonide) were titrated against either the provocative dose of mannitol causing a 10% fall in FEV(1) (PD(10)) (AHR strategy) or a control group (reference strategy) over a 1-year period.
  
  
  RESULTS
  One hundred nineteen participants (n = 61 AHR, n = 58 control) completed the study. Time to first mild exacerbation was not significantly different: hazard ratio, 1.29; 95% CI, 0.716-2.31; P = .40. Although there were 27% fewer total number of mild exacerbations over 12 months in AHR vs control groups (n = 84 vs n = 115, P = .03), there was no difference in severe exacerbations (n = 12 vs n = 13). No other significant differences were seen between groups with the exception of mannitol PD(10) and ICS dose. There was a 1.52 (95% CI, 0.61-2.42; P = .001) doubling dose difference in mannitol PD(10) between AHR vs control groups. The final mean daily ciclesonide dose was higher (P < .0001) in AHR vs control groups (514 μg vs 208 μg), with no associated significant suppression of overnight urinary cortisol/creatinine. Significant improvements were seen within the AHR group but not the control group for the provocative concentration of methacholine causing a 20% fall in FEV(1) (P < .05), salivary eosinophilic cationic protein (P < .05), exhaled nitric oxide (P < .05), symptoms (P < .005), and reliever use (P < .001).
  
  
  CONCLUSIONS
  Mannitol challenge was well tolerated in a primary care setting. Using mannitol resulted in exposure to a higher dose of ciclesonide, which was associated with equivocal effects on exacerbations without associated adrenal suppression. Large-scale trials using mannitol in patients with more severe disease may now be warranted to further define its role.
  
  
  BACKGROUND
  ClinicalTrials.gov; No.: NCT01216579; URL: www.clinicaltrials.gov.
authors: Asthma and Allergy Research Group, Ninewells Hospital and Medical School, University of Dundee, Dundee. Electronic address: brianlipworth@gmail.com.
authors: Brian J
authors: BJ
authors: Lipworth
authors: Asthma and Allergy Research Group, Ninewells Hospital and Medical School, University of Dundee, Dundee.
authors: Philip M
authors: PM
authors: Short
authors: Asthma and Allergy Research Group, Ninewells Hospital and Medical School, University of Dundee, Dundee.
authors: Peter A
authors: PA
authors: Williamson
authors: Asthma and Allergy Research Group, Ninewells Hospital and Medical School, University of Dundee, Dundee.
authors: Karine L
authors: KL
authors: Clearie
authors: Asthma and Allergy Research Group, Ninewells Hospital and Medical School, University of Dundee, Dundee.
authors: Thomas C
authors: TC
authors: Fardon
authors: Bute Medical School, University of St. Andrews, St. Andrews, Scotland.
authors: Cathy M
authors: CM
authors: Jackson
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000627:therapeutic use*; D001249:Asthma / Q000188:drug therapy* / Q000503:physiopathology; D001985:Bronchial Provocation Tests; D004305:Dose-Response Relationship, Drug; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008137:Longitudinal Studies; D008353:Mannitol / Q000008:administration & dosage / Q000009:adverse effects*; D008875:Middle Aged; D011282:Pregnenediones / Q000008:administration & dosage / Q000627:therapeutic use*; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D000305:Adrenal Cortex Hormones; D011282:Pregnenediones; D008353:Mannitol; C120481:ciclesonide