When to add an inhaled corticosteroid (ICS) for an asthmatic patient with a cold-induced cough?

From the Guidelines

A steroid inhaler should be added for an asthmatic patient with a cold-induced cough when their symptoms are not adequately controlled by their regular rescue inhaler alone, as suggested by the most recent and highest quality study 1. Specifically, consider adding a steroid inhaler if:

• The patient is using their rescue inhaler more than 2-3 times per week
• Cold symptoms are consistently triggering asthma exacerbations
• The patient experiences nighttime coughing or waking due to asthma symptoms Start with a low-dose inhaled corticosteroid, such as:

• Fluticasone (Flovent): 88 mcg, 1-2 puffs twice daily
• Beclomethasone (QVAR): 40 mcg, 1-2 puffs twice daily
• Budesonide (Pulmicort): 90 mcg, 1-2 puffs twice daily Instruct the patient to use the steroid inhaler regularly as prescribed, even when not experiencing symptoms, as recommended by the Chest guideline and expert panel report 1. It may take 1-2 weeks to see full benefit, and the patient should continue use for at least 4-6 weeks or throughout the cold season, then reassess, based on the evidence from the Chest guideline and expert panel report 1. Steroid inhalers work by reducing airway inflammation, which is often exacerbated during viral infections, as noted in the study 1. This helps prevent asthma symptoms and reduces the frequency of exacerbations, ultimately improving overall asthma control and reducing the need for rescue medications, as suggested by the Global Initiative for Asthma (GINA) and the Chest guideline and expert panel report 1.

The evidence base supporting the step-wise treatment for asthma is very strong, and the use of inhaled corticosteroids as first-line treatment for chronic cough due to asthma is recommended, with a Grade 1B recommendation 1. In adult and adolescent patients with chronic cough due to asthma as a unique symptom (cough variant asthma [CVA]), inhaled corticosteroids should be considered as first-line treatment, as suggested by the Chest guideline and expert panel report 1. If response is incomplete, stepping-up the inhaled corticosteroid dose and considering a therapeutic trial of a leukotriene inhibitor after reconsideration of alternative causes of cough may be necessary, as recommended by the Chest guideline and expert panel report 1. Beta-agonists could also be considered in combination with ICS, as noted in the study 1.

Overall, the use of steroid inhalers in asthmatic patients with cold-induced cough can help improve symptoms, reduce exacerbations, and improve overall asthma control, as supported by the evidence from the Chest guideline and expert panel report 1.

From the FDA Drug Label

When choosing the starting dosage strength of Wixela Inhub®, consider the patients’ disease severity, based on their previous asthma therapy, including the ICS dosage, as well as the patients’ current control of asthma symptoms and risk of future exacerbation. For patients who do not respond adequately to the starting dosage after 2 weeks of therapy, replacing the current strength of Wixela Inhub with a higher strength may provide additional improvement in asthma control. If a previously effective dosage regimen fails to provide adequate improvement in asthma control, the therapeutic regimen should be reevaluated and additional therapeutic options (e.g., replacing the current strength of Wixela Inhub® with a higher strength, adding additional ICS, initiating oral corticosteroids) should be considered.

The decision to add an inhaled corticosteroid (ICS) for an asthmatic patient with a cold-induced cough should be based on the patient's disease severity and current control of asthma symptoms. If the patient is not adequately controlled on their current therapy, adding an ICS may be considered as part of the therapeutic regimen. However, the exact timing of when to add an ICS is not explicitly stated in the drug label. 2

From the Research

Asthmatic Patients with Cold-Induced Cough

• The decision to add an inhaled corticosteroid (ICS) for an asthmatic patient with a cold-induced cough should be based on the severity of symptoms and the patient's response to initial treatment 3.
• Asthmatic patients sensitive to cold stimulation experience more frequent acute exacerbations and have more obvious impairment of lung function compared to cold-insensitive patients 3.
• The use of ICS, such as fluticasone propionate, in combination with a long-acting β2 receptor agonist (LABA) and montelukast sodium, can improve clinical symptoms and lung function in asthmatic patients, including those with cold-induced cough 3.

Inhaled Corticosteroid Therapy

• ICS therapy, such as fluticasone propionate, is effective in moderate-to-severe asthma and can improve lung function and symptom control 4, 5, 6.
• The addition of a LABA, such as salmeterol, to ICS therapy can provide greater improvements in pulmonary function and symptom control compared to increasing the dose of ICS alone 4, 7.
• The anti-inflammatory profile of ICS combined with salmeterol in asthmatic patients suggests that salmeterol has an additive or complementary anti-inflammatory effect to that of ICS 7.

Treatment Considerations

• The treatment of asthmatic patients with cold-induced cough should be individualized based on the severity of symptoms and the patient's response to initial treatment 3.
• The use of ICS, LABA, and other medications, such as montelukast sodium, should be considered in the treatment of asthmatic patients with cold-induced cough 3.
• The airway inflammatory phenotype in cold-sensitive asthmatic patients is characterized by the domination by neutrophilic subtype, which may require different treatment approaches compared to classic asthma 3.