Recommending Oral Probiotics to Reduce Winter Antibiotic Prescriptions in People With Asthma: A Pragmatic Randomized Controlled Trial

Oral Probiotics to Reduce Winter Antibiotic Prescriptions in People With Asthma represents the latest in a long line of failed attempts to find better treatments for this prevalent condition. I applaud the authors' interest in researching novel asthma treatments and want to draw their attention to a neglected approach that deserves its own pragmatic trial. Novel asthma treatments are desperately needed. Asthma experts estimate that between 5-15% of ALL people with asthma have severe asthma that is REFRACTORY to current guideline treatments. Overall, 50% of people with asthma remain suboptimally controlled, even when they are treated.[1,2]

Conventional studies (such as doubling the dose of inhaled corticosteroids, or adding long-acting bronchodilators) and those of novel therapies (such as vitamin D supplementation) have produced disappointing [3] or negative [4] results in people with uncontrolled asthma. In my estimation, the most promising novel therapy for asthma is longterm administration of a macrolide (azithromycin in particular). Ironically, good evidence for macrolide efficacy exists for every chronic lung disease (e.g., diffuse panbronchiolitis, cystic fibrosis, bronchiectasis, COPD, even post-lung transplant bronchiolitis obliterans) EXCEPT asthma. This lacune is due to lack of funding to produce evidence, not to a body of evidence for lack of effect.[5]

I encourage investigators with an interest in novel asthma treatments to review the existing meta-analyses of macrolides for asthma (all of them recommend further research). For example, Reiter et al.[6] found positive effects of macrolides for the longterm management of asthma that included improved peak expiratory flow, improved symptoms, better quality of life, and less airway hyper-reactivity. The most recent Cochrane review of macrolides for asthma found (after correction of a data entry error) positive effects on sympotms and FEV1.[7] These meta-analyses do not include azithromycin-treated patients who declined to be randomized, yet experienced very large clinical benefits (that even persisted long after treatment was completed).[8] A cost-benefit analysis compared azithromycin treatment in this group [8] to increased or added conventional treatments.[3] Making all assumptions favorable to conventional approaches, the analysis found that azithromycin was 10 times more cost-effective than conventional approaches (data available on request). I encourage all investigators with an interest in novel asthma treatments to familiarize your selves with this promising approach - and then consider acting.

1. Demoly P et al. Update on asthma control in five European Countries; results of a 2008 survey. Eur Respir Rev. 2010;19:150-157
2. Schatz M et al. Reliability and predictive validity of the Asthma Control Test administered by telephone calls using speech recognition technology. J Allergy Clin Immunol 2007;119:336-343
3. Peters SP et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. 2010;363:1715-1726
4. Castro M et al. Effect of vitamin D3 on asthma treatment failures in adults with symptomatic asthma and lower vitamin D levels: the VIDA randomized clinical trial. JAMA 2014;311:2083-2091
5. Hahn DL. A Cure for Asthma? What Your Doctor Isn't Telling You, and Why. Peoples Pharmacy Press 2013. ISBN 978-0-9896960-0-5, 192 pages.
6. Reiter J et al. Macrolides for the long-term management of asthma - a meta-analysis of randomized clinical trials. Allergy 2013;68:1040-1049
7. Kew KM et al. Macrolides for chronic asthma. Cochrane Database of Systematic Reviews. 2015, Issue 9. Art No.:CD002997. DOI: 10.1002/14651858.CD002997.pub4
8. Hahn DL et al. Azithromycin for bronchial asthma in adults: an effectiveness trial. J Am Board Fam Med 2102;25:442-459

Competing interests: None declared