What is the recommended treatment for mild persistent asthma using a daily medium dose of inhaled corticosteroids (ICS)/formoterol and an as-needed short-acting beta-agonist (SABA)?

From the Guidelines

For mild persistent asthma, the recommended treatment is not a daily medium dose of inhaled corticosteroids (ICS) combined with formoterol and an as-needed short-acting beta-agonist (SABA), but rather either daily low-dose ICS and as-needed SABA or as-needed ICS and SABA used concomitantly, as conditionally recommended by the Expert Panel with moderate certainty of evidence 1.

Key Considerations

• The use of daily medium dose ICS/formoterol with an as-needed SABA is not the preferred approach for mild persistent asthma, according to the most recent guidelines 1.
• Instead, patients can be treated with either daily low-dose ICS and as-needed SABA or as-needed ICS and SABA used concomitantly, which has been shown to be effective in controlling asthma symptoms and reducing exacerbations 1.
• The as-needed ICS and SABA approach may be particularly attractive to patients who are concerned about ICS side effects, as it reduces total ICS exposure while maintaining asthma control 1.
• Patients should be instructed on the proper use of their inhalers, including rinsing their mouth after using the ICS inhaler to prevent oral thrush, and keeping track of their rescue inhaler use to monitor asthma control 1.

Treatment Details

• Typical low-dose ICS regimens include 100-250 mcg of fluticasone or equivalent twice daily.
• SABA rescue inhalers, such as albuterol or salbutamol, should be used as needed for breakthrough symptoms, typically 1-2 puffs every 4-6 hours as required.
• The choice between daily low-dose ICS and as-needed SABA or as-needed ICS and SABA should be made on a case-by-case basis, taking into account patient preferences and concerns 1.

From the Research

Treatment Options for Mild Persistent Asthma

The recommended treatment for mild persistent asthma using a daily medium dose of inhaled corticosteroids (ICS)/formoterol and an as-needed short-acting beta-agonist (SABA) is based on several studies.

• A study from 2 discusses various treatment options for mild persistent asthma, including the use of a combination ICS/long-acting beta2-agonist inhaler once-daily together with as-needed SABA.
• Another study from 3 provides a scientific rationale for the combination of ICS and long-acting beta2-agonists, stating that this combination addresses complementary aspects of the pathophysiology of asthma.

Efficacy of ICS/Formoterol Combination

• A study from 4 demonstrates the efficacy and safety of budesonide/formoterol inhalation aerosol in the treatment of persistent asthma, showing that this combination is effective in controlling asthma symptoms.
• The study from 5 explores the use of as-needed ICS in mild persistent asthma, showing mixed results compared to continuous therapy.

As-Needed ICS-LABA in Mild Asthma

• A recent study from 6 reviews the evidence for the use of as-needed ICS-LABA in mild asthma, concluding that there is insufficient evidence to systematically recommend this approach instead of SABA on request for GINA step 1 or as a replacement for chronic ICS in GINA step 2.
• However, the same study notes that the combination of ICS-LABA as rescue medication provides better asthma control than short-acting β-agonists alone in GINA step 2 patients, although the superiority is slight 6.

Key Findings

• The use of a daily medium dose of ICS/formoterol and an as-needed SABA is a viable treatment option for mild persistent asthma 2, 3.
• The combination of ICS and long-acting beta2-agonists has a strong scientific rationale and is effective in controlling asthma symptoms 3, 4.
• As-needed ICS-LABA may be beneficial in mild asthma, but more evidence is needed to support its use as a first-line treatment 6.