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Proton-Pump Inhibitor Therapy in Poorly Controlled Asthma

Posted May 09 2009 10:31pm
I'm terribly disappointed in the conclusion drawn from this study. A recent article in NEJM, authored by physicians at Johns Hopkins, determined that Nexium 40 mg dosed twice a day for twenty-four months DOES NOT help in asthmatics if they lacked classic GERD symptoms. The study has been praised by many scientists based on its design, etc. I trust their findings but I DO NOT endorse their conclusion. I believe the findings of limited benefit since the only valid conclusion I can make is no improvement in asthmatics AT THIS DOSE. I believe they could individualize a dose and treatment regime constructed to achieve improved outcomes in many patients with pulmonary problems by attempting to dose to the end point of eradication of symptoms. I have SEEN asthmatics and cough patients resolve by titrating (adjusting) the dose over a wide range to control the disorder. I have seen this in numerous cases. I believe the design of the study is flawed by the fixed dose as an arbitrary endpoint. It seems the study was designed from the opinion that "a single fixed dose fits all". The FAILURE to adjust the patients dose to achieve sign and symptom remission virtually ensures poor outcomes in numerous cases. For example some diabetics may require only 5 units of supplemental insulin for sugar control while another might require 50, 90 or even 100 units. Dosages of many medications must be individualized to achieve favorable outcomes. If you only gave each dabetic the lowest dose of insulin , tracking the outcomes would "prove" that insulin AT THIS DOSEAGE failed to control the majority of diabetes mellitus My experience is consistent with others who have found success by adjusting (titrating) the dose of anti-secretory therapy in EACH PATIENT, INDIVIDUALLY based on their personal response. Casteel reported in 1999 that the oral bioavailability of omeprazole varied patient to patient by a factor of "at least six fold". My experience indicates that GERD therapy needs to be based on individual outcomes on a case to case person by person basis. I've seen patients who needed double or triple the "ordinary" dose to safely achieve disease and symptom control. (Omeprazole has been used in Zollinger-Ellison Syndrome at 9-18 times the ordinary dose with no FDA limitations for at least 5 years consecutively).
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