A long time ago in a galaxy far, far away (1958, Derby, UK in fact), Harry Morrow-Brown used his microscope from his medical school days to show that only those adults with airway disease and sputum eosinophilia responded to oral prednisolone [1], thus preventing this most powerful of medications being consigned to the asthma dustbin of history. Subsequent work led to steroid therapy moving from oral to inhaled [2], and thus nearly three decades ago came, not the dawning of the Age of Aquarius, but that of the age of inhaled corticosteroids (ICS). This age brought undoubted and huge benefits, and there can be no question but that low dose ICS when regularly and properly administered are one of the safest and most effective treatments in the respiratory armamentarium. However, in the aftermath of the discovery of a really effective treatment, instead of kicking on to the next stage, we have stagnated in an unsatisfactory comfort zone. Asthma diagnosis is inaccurate [3–5], but this does not matter, because ICS are so safe you may as well try them for any respiratory symptoms, and anyway, there is a big placebo effect. Medications are escalated uncritically, without thought as to why low doses are not working. Asthma mortality does remain unacceptably high [6], a red flag in our present morass of complacency. Finally, we get into sterile debates about whether, for example, survivors of pre-term birth have “asthma”. Crucially, we have lost sight of the great lesson taught to us by Dr Morrow-Brown, namely that all asthmas are not equal. The age of ICS, which started as the first use of personalised treatment, did not become the platform for building precision medicine, but instead, has reached an era of “put steroids in the tap water”, and writing and re-writing “evidence based guidelines”, which assume homogeneity and have signally failed to improve outcomes, while replacing serious thought about the problems. The Lancet commission on asthma proposes new paradgims; especially to ask “what asthma do I have?” http://ow.ly/YVpG30eaeN5

中文翻译：

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哮喘之后：星球大战和星际迷航

很久以前，在一个遥远的星系（实际上是 1958 年，英国德比），Harry Morrow-Brown 使用他在医学院时代的显微镜表明，只有那些患有气道疾病和痰嗜酸性粒细胞增多症的成年人对口服泼尼松龙有反应 [ 1]，从而防止这种最强大的药物被扔进历史上的哮喘垃圾箱。随后的工作导致类固醇治疗从口服转向吸入 [2]，因此近 30 年前，不是水瓶座时代的到来，而是吸入皮质类固醇 (ICS) 时代的到来。这个时代带来了毋庸置疑的巨大好处，毫无疑问，低剂量 ICS 在定期和适当给药的情况下是呼吸设备中最安全和最有效的治疗方法之一。然而，在发现了一种真正有效的治疗方法之后，我们没有进入下一阶段，而是停滞在一个令人不满意的舒适区。哮喘诊断是不准确的 [3-5]，但这并不重要，因为 ICS 非常安全，您不妨尝试它们来治疗任何呼吸道症状，无论如何，安慰剂效应很大。药物不加批判地升级，没有考虑为什么低剂量不起作用。哮喘死亡率确实仍然高得令人无法接受[6]，这是我们目前自满泥潭中的一个危险信号。最后，我们就早产幸存者是否患有“哮喘”等问题展开了毫无意义的辩论。至关重要的是，我们忽略了 Morrow-Brown 博士教给我们的重要一课，即所有哮喘病都不尽相同。以个体化治疗为首的ICS时代，并没有成为构建精准医疗的平台，反而，已经到了“在自来水中注入类固醇”的时代，以及编写和重写“循证指南”的时代，这些指南假设同质化，显然未能改善结果，同时取代了对问题的认真思考。柳叶刀哮喘委员会提出了新的范式；尤其是问“我有什么哮喘？” http://ow.ly/YVpG30eaeN5