This review provides an overview of the role of long-term treatment of severe asthma with oral corticosteroids (OCS) and its associated side-effects in adults. It is based on a systematic literature search conducted in MEDLINE, Embase and the Cochrane Library to identify relevant studies. After a short overview of severe asthma and its treatment we present studies showing a dose-response relationship in asthmatic patients treated with OCS and then consider by organ systems the undesired effects demonstrated in clinical and epidemiological studies in patients with OCS-dependent asthma. It was found that the risk of developing various OCS-related complications, including infections, diabetes and osteoporosis as well as psychiatric disorders, was higher for patients with long-term exposure to OCS compared with control groups. In addition, studies showed a significant increase in healthcare resource utilisation due to OCS treatment. Therefore, it is incumbent on every clinician to carefully weigh the potential benefit of preventing loss of asthma control against this risk before opting to prescribe long-term OCS therapy. Effective corticosteroid-sparing strategies must be used and should aim at short-term use with the lowest effective dose and start tapering as soon as possible until OCS therapy is terminated.

Financial restrictions and a stronger focus on outcomes assessment require rational decisions regarding the allocation of resources in the health-care system. Such decisions are based on medical, ethical, and economic considerations. Management of the health-care system requires both a medical and an economic orientation at the overall societal level and regarding the selection of appropriate health-care services in hospitals and ambulatory practices. The practical application of health economic methods can be an important tool assuring more transparency and in validating necessary decisions.The methods made available by health economic research represent a rational approach for a structured resource allocation in the health-care system and facilitate the process of a relative assessment of various treatment methods with each other. Although the focus of such studies frequently rests on pharmaceuticals, health economic evaluation methods are suitable for all medical services, procedures, and health-care programs. But, what is assessed from which perspective,

Smoking is a high-risk behaviour affecting health and economic welfare of society. Thus it is important to quantify the economic burden smoking places on social institutions in Germany. Approximately 33.4% of the male and 20.4% of the female population are current smokers. This study investigates the health care costs of smoking based on 1996 figures, focusing on the seven most frequent diseases associated with the inhalation of tobacco smoke: chronic obstructive pulmonary disease (COPD, international classification of diseases (ICD) 490±491); lung cancer (ICD 162); stroke (ICD 434±438); coronary artery disease (ICD 410±414); cancer of the mouth and larynx (ICD 140±149, 161) and artherosclerotic occlusive disease (ICD 440).A data search was carried out on MEDLINE, the German Institute for Medical Documentation and Information, and the Internet as well as in databases of health insurance companies and the German Federal institute of statistics. Direct and indirect costs were calculated separately.The results estimate the total smoking related health care costs (attributable fraction due to smoking) for COPD to be 5.471 billion EURO (73%), for lung cancer 2.593 billion EURO (89%), for cancer of the mouth and larynx 0.996 billion EURO (65%), for stroke 1.774 billion EURO (28%), for coronary artery disease 4.963 billion EURO (35%) and for artherosclerotic occlusive disease 0.761 billion EURO (28%). The economic burden of smoking related health care costs for Germany is 16.6 billion EURO. Smoking is therefore responsible for 47% of the overall costs of these diseases (35.2 billion EURO).In the view of the high costs for smoking, of which almost 50% are due to respiratory disease, pneumologists should enhance their effort in primary, secondary and tertiary prevention. Eur Respir J 2000; 16: 385±390.

BackgroundPhysical training has been shown to improve exercise capabilities in patients with asthma. Most studies focused on children and younger adults. Previously, the maximum program duration was six months. It is not known whether the same results may be obtained with lower intensity programs and sustained for time periods longer than 6 months. This controlled study was undertaken to investigate the effects of a moderate intensity outpatient training program of one year duration on physical fitness and quality of life in adults with asthma.Methods21 adult asthmatics (mean age 56 ± 10 years) were allocated to outpatient training (n = 13) or standard care (n = 8). Exercise consisted of once weekly, 60-minute sessions of moderate intensity. Assessments at baseline and after one year included cardiopulmonary exercise testing and Short Form-36 and Asthma Quality of Life Questionnaires.ResultsFollowing one year of exercise, relevant improvements were observed in the training group for maximum work capacity (p = 0.005), peak oxygen uptake (p < 0.005), O2pulse (p < 0.05), maximum ventilation (p < 0.005), and most of the quality of life domains. No changes were observed in the control group.ConclusionsA physiotherapist-led, long-term, moderate-intensity exercise program of one year duration can induce clinically relevant improvements in exercise capabilities and health-related quality of life in well-motivated adults with asthma.Trial registrationclinicaltrials.gov NCT01097473. Date trial registered: 31.03.2010.

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