When to prescribe inhaled corticosteroids (ICS) in patients with mild asthma?

From the Guidelines

Inhaled corticosteroids (ICS) should be prescribed for patients with mild asthma, as they address the underlying airway inflammation and reduce exacerbation risk, with the most recent guidelines suggesting either daily low-dose ICS and as-needed SABA for quick-relief therapy or as-needed ICS and SABA used concomitantly for individuals aged 12 years and older 1. The decision to prescribe ICS in mild asthma should be based on the patient's symptoms, clinical findings, and spirometry results.

• For patients with very intermittent symptoms (less than twice monthly), as-needed use of low-dose ICS combined with a short-acting beta-agonist (SABA) like budesonide-formoterol (160/4.5mcg) taken when symptoms occur is an effective alternative to daily ICS, as suggested by the 2020 focused updates to the asthma management guidelines 1.
• For patients with more regular symptoms (twice monthly or more), daily low-dose ICS provides better symptom control and lung function improvement. ICS work by reducing airway inflammation, decreasing mucus production, and preventing airway remodeling that can lead to permanent lung function decline. Starting ICS early in the disease course, even with mild symptoms, helps prevent asthma progression and reduces the risk of severe exacerbations that might require emergency care or hospitalization, as supported by the guideline-defining asthma clinical trials of the national heart, lung, and blood institute's asthma clinical research network and childhood asthma research and education network 1. It is essential to consider the dose and potential side effects of ICS, as higher doses may increase the risk of systemic effects, such as reduced linear growth rate in children or lower bone mineral density in adults, as discussed in the Mayo Clinic Proceedings article on managing asthma in primary care 1.

From the FDA Drug Label

The efficacy of budesonide inhalation suspension at doses of 0.25 mg, 0.5 mg, and 1 mg once daily was evaluated in 344 pediatric patients, 12 months to 8 years of age, with mild to moderate persistent asthma (mean baseline nighttime asthma symptom scores of the treatment groups ranged from 1.07 to 1.34) who were not well controlled by bronchodilators alone.

Prescription of ICS in Mild Asthma:

• ICS, such as budesonide, can be prescribed in patients with mild asthma who are not well-controlled by bronchodilators alone.
• The decision to prescribe ICS should be based on the individual patient's asthma severity and response to treatment.
• In patients with mild asthma, ICS can be initiated at a low dose, such as 0.25 mg once daily, and titrated up as needed to achieve adequate control of symptoms.
• It is essential to monitor the patient's response to ICS treatment and adjust the dose or add other therapies as needed to achieve optimal asthma control 2.

From the Research

Inhaled Corticosteroids (ICS) in Mild Asthma

• The use of ICS in mild asthma is a topic of ongoing research and debate 3, 4, 5, 6, 7.
• Studies have shown that ICS can improve lung function, reduce exacerbations, and prevent future adverse outcomes in patients with mild asthma 3, 4.
• The Global Initiative for Asthma guidelines recommend the use of ICS in patients with mild persistent asthma, with a low dose of 100-250 μg of fluticasone propionate or equivalent per day 6.

Timing of ICS Prescription

• ICS should be prescribed to patients with mild asthma who have a history of exacerbations or who have not achieved adequate control with short-acting beta-agonists alone 4, 5.
• ICS can be prescribed as a single inhaler, containing both a steroid and a fast-acting beta₂-agonist, to simplify treatment regimens and improve adherence 5.
• The decision to prescribe ICS should be based on individual patient needs and circumstances, taking into account factors such as symptom severity, lung function, and history of exacerbations 3, 4, 6, 7.

Dose and Duration of ICS Treatment

• The optimal dose and duration of ICS treatment in mild asthma are not well established, but studies suggest that low doses (200-250 μg of fluticasone propionate or equivalent per day) may be effective in achieving therapeutic benefits while minimizing systemic adverse effects 6.
• ICS treatment should be continued for at least 3-6 months to assess its effectiveness, and then stepped down or withdrawn if symptoms are well controlled 7.
• Regular review and adjustment of ICS treatment is necessary to ensure that patients receive the most effective and safe treatment for their asthma 3, 4, 6, 7.