From the Guidelines
The recommended approach for asthma management is to use a medium dose Inhaled Corticosteroid (ICS) with an as-needed short-acting beta-agonist (SABA) component, as this has been shown to achieve noninferior asthma control while reducing total ICS exposure 1. When considering a daily medium dose ICS and an as-needed component for asthma, it's essential to weigh the benefits and drawbacks of different approaches.
- A medium dose ICS can be defined as 250-500 mcg of fluticasone propionate (or equivalent) per day, taken in divided doses.
- The as-needed component typically consists of a SABA, such as albuterol, which can be used every 4-6 hours as needed.
- However, using ICS with each dose of as-needed SABA has been suggested to result in asthma control that is noninferior to routine daily ICS use, while reducing total ICS exposure 1.
- This approach may be particularly attractive to patients concerned about ICS side effects, and can be a subject of shared decision making with the patient.
- It's worth noting that an as-needed ICS/SABA strategy may be inferior to routine daily ICS in terms of asthma control as reflected by symptoms 1, highlighting the importance of individualized treatment plans.
- Proper inhaler technique and mouth rinsing after ICS use are crucial for medication effectiveness and preventing oral thrush.
From the FDA Drug Label
The daily doses of beclomethasone dipropionate 462 to 672 mcg; flunisolide 1,250 to 2,000 mcg; fluticasone propionate inhalation aerosol 440 mcg; or triamcinolone acetonide 1,100 to 1,600 mcg
The recommended daily dose of a medium dose Inhaled Corticosteroid (ICS) is between 462 to 672 mcg of beclomethasone dipropionate, 1,250 to 2,000 mcg of flunisolide, 440 mcg of fluticasone propionate inhalation aerosol, or 1,100 to 1,600 mcg of triamcinolone acetonide.
- Key points:
- Medium dose ICS: 462 to 672 mcg of beclomethasone dipropionate
- Medium dose ICS: 1,250 to 2,000 mcg of flunisolide
- Medium dose ICS: 440 mcg of fluticasone propionate inhalation aerosol
- Medium dose ICS: 1,100 to 1,600 mcg of triamcinolone acetonide As for the as-needed component for asthma management, the label does not provide a direct recommendation. 2 2
From the Research
Daily Medium Dose ICS and As-Needed Component for Asthma Management
- The recommended daily dose of a medium dose Inhaled Corticosteroid (ICS) is between 250 to 500 μg of fluticasone propionate or equivalent 3.
- A study found that a daily dose of 800 μg of the ICS budesonide reduced severe exacerbation rates by 49% compared to a low dose of 200 μg daily, and addition of the LABA formoterol to budesonide (800 μg) led to a 63% reduction 4.
- The use of a single combined (fast-onset beta₂-agonist plus an inhaled corticosteroid (ICS)) inhaler only used as needed in people with mild asthma has been found to be effective in reducing exacerbations and hospital admissions 5.
- The combination of salmeterol 50 μg and fluticasone 250 μg in a single dry powder inhaler was superior to twice the dose of FP (500 μg) for the treatment of symptomatic moderate asthma 6.
- Continuous administration of ICSs in low to medium dose over many years is well tolerated, and the use of as-needed ICSs in patients with mild persistent asthma is promising as a potential step-down therapy 7.
As-Needed Component
- The as-needed component of asthma management can include a fast-acting beta₂-agonist (FABA) such as formoterol or terbutaline 5.
- The use of a single combined FABA/ICS inhaler as needed has been found to be effective in reducing exacerbations and hospital admissions, and may be associated with less average daily exposure to inhaled corticosteroids than regular ICS 5.