Inhaled corticosteroids are the mainstay of anti-inflammatory treatment in patients with chronic asthma, and most patients’ symptoms are controlled by low or moderate doses of these agents. However, there are some patients with chronic severe asthma whose symptoms are inadequately controlled by high doses of inhaled corticosteroids and maximal bronchodilator therapy. Such patients require increasingly frequent courses of oral corticosteroids, often culminating in their long term use.

Until recently in the UK, budesonide (Pulmicort Respules, Astra Pharmaceuticals) was the only corticosteroid available for nebulisation. Fluticasone propionate (Flixotide Nebules, Glaxo Wellcome) was launched in late 1998, and is being actively marketed. The 1995 British Thoracic Society asthma guidelines state, however, that there are “. . . no published controlled trials of the effectiveness of nebulised budesonide in adults”.1 This review aims to address whether these guidelines hold true, or whether new evidence has emerged which should lead us to review this policy.

The evidence for the effectiveness of nebulised corticosteroids in the treatment of stable asthma is reviewed, together with a discussion of whether there is any evidence that their use allows a reduction in regular oral corticosteroid dose in patients with severe asthma. In considering this evidence it is important to compare the side effects of nebulised corticosteroids with those of high dose inhaled corticosteroids and with those of oral corticosteroids. Studies which compare nebulised corticosteroid with oral corticosteroid in the treatment of acute exacerbations of asthma are also reviewed. It is important to consider patient preference for nebulised, inhaled or oral therapy, which is closely linked with compliance with treatment. Finally, in such a review it is vital to consider the cost implications of any change in practice in the treatment of patients with acute and chronic asthma.

There are a large number of case reports and uncontrolled …