Report of a workshop assessing the risks and benefits of inhaled anti-inflammatory treatment for asthma.

The causes of asthma remain unknown although it is now clear that the underlying pathology of the disease, even in its mildest forms, is one of chronic persistent inflammation. This fact is recognised in many national, and more recently, international guidelines, which recommend that treatment in all but the most mild episodic asthma should be aimed at the underlying pathology rather than at suppression of symptoms: maintenance anti-inflammatory drugs should be introduced when prn ,8z-agonist use exceeds three times a week [1]. The guidelines also acknowledge that maintenance use of ,8z-agonists is associated with an overall worsening in asthma control. Thus, an increasing requirement for the use of these agents should serve as an indication to start or increase daily inhaled anti-inflammatory therapy. Adoption of the guidelines means that large numbers of patients not previously treated will receive an anti-inflammatory drug on a chronic basis. The international guidelines recommend three drugs: sodium cromoglycate, nedocromil sodium, and the inhaled corticosteroids, but which drug should be used first is left open to individual choice, apart from a recommendation that all children should begin with a trial of sodium cromoglycate. We suggest that, given equal efficacy in a given situation, safety should be a prime concern, especially in mild asthma and in the more vulnerable age groups -,children and the elderly. It is particularly important to consider drug safety in mild-tomoderate asthma since this probably represents the largest group of asthmatic