Therein is a statement that cromolyn sodium MDI 1 mg/puff is unlikely to be effective and, therefore, where the 20-mg doses (nebulized or powder inhaler) are not available, low-dose inhaled corticosteroids are recommended.
I strongly disagree with this statement for the following reasons:
- The only reference given in support of this statement (reference 91) is a study on exercise-induced asthma in which protection with cromolyn sodium 2 mg was as good as with 20 mg and 40 mg, 20 min and 150 min after drug administration, respectively, and only at 270 min was 20 mg better than 2 mg. Attempting to predict overall clinical success with cromolyn sodium from the duration of protection on exercise-induced asthma yields very poor predictive values that do not reach statistical significance. 2 2. There is ample evidence that cromolyn sodium MDI 2 mg/dose (1 mg/puff) has good clinical efficacy both in children and adults, [3] including our long-term study 8 (quoted by Warner et al., as reference 92, for cromolyn efficacy right after the negative statement on the 2-mg dose). 3. Several studies compared head-to-head, cromolyn MDI 2 mg vs. 20 mg by dry powder inhaler, and out of five studies, four found equal efficacy, 9-12 and only one found greater efficacy for the powder. Patient preference was generally in favor of MDI. Therefore, there is ample evidence for the efficacy of the 2-mg dose (1 mg/puff) and very little evidence of the superiority of a 20-mg dry powder inhaler over the 2-mg MDI dose. In fact, in their original recommendations, Warner et al. suggested that the 1-mg/puff MDI dose can be used in countries where the 5-mg/puff is not available.