Treat patients who have nocturnal asthma with anti-inflammatory drugs first.

an evening dosage, which resulted in larger bronchodilatation at 7 am. D'Alonzo et al, however, do not further discuss the role of p-agonists such as bambuterol in the pharmacotherapy of noctur¬ nal asthma. Several research groups have shown that the presence of nocturnal symptoms is related to the degree of airway responsive¬ ness.1,2 Airway inflammatory processes are known to influence air¬ way responsiveness. One might thus hypothesize that patients with asthma with more active airway inflammation are likely to have nocturnal symptoms. Indeed, cellular activation during the day, as measured in BAL fluid, is higher in asthmatics with than without nocturnal symptoms.3 In addition, inflammatory cell numbers in BAL fluid are increased at night in subjects with nocturnal asthma, but not in normal subjects.4 Therefore, it seems obvious to use antiinflammatory drugs in the treatment of nocturnal asthma. Previously, we have compared the effects of the inhaled cortico¬ steroid budesonide (0.4 pg bid) and bambuterol (20 mg at 8 pm) on lung function and symptoms of nocturnal asthma in a placebocontrolled study.5 Bambuterol produced a significant nocturnal bronchodilation and reduction of histamine airway responsiveness, and improvement of nocturnal wheeze, dyspnea, and quality of sleep. In comparison with bambuterol, however, treatment with budesonide resulted in a larger improvement in airway responsive¬ ness at 4 am (2.1 vs 0.8 doubling concentrations) and a greater beneficial effect on nocturnal dyspnea and wheeze. In conclusion, information so far suggests that nocturnal symp¬ toms ofasthma are a reflection ofmore severe airway inflammation, and we advocate the use of anti-inflammatory drugs as first-line