LAUSR

measures, including environmental control, use of adjunct therapies such as long-acting inhaled bronchodilators, and in the more severe patient, by the early introduction of biologics. However, prevention of OCS use and related exacerbations should be a priority, which could be avoided in some patients by using high doses of ICS. In this regard, in a study over a median period of 10 years (maximum, 30 yr), we showed that when the dose of ICS/prednisone was adjusted to keep sputum eosinophils under control, exacerbations and the rate of decline of lung function were significantly reduced, although at a price of adverse effects, mainly when OCS was needed (7). Adverse effects of high doses of ICS have been confounded by methodologic issues and intercurrent OCS use, and there is probably also a variation in susceptibility to those effects from one patient to another. We therefore agree with Beasley and colleagues that we should prevent overdosing with ICS when not necessary, and that in this regard, there is a significant care gap in asthma management with an underutilization of noninvasive measurements of airway inflammation, particularly in moderate to severe asthma. We endorse the need for rigorous dose–response studies of ICS to be conducted in patients who are well characterized on the basis of their inflammatory endotypes. n