What are the effects of inhaled corticosteroids (ICS) for asthma?

From the Guidelines

Inhaled corticosteroids are the most effective long-term control medication for asthma, improving symptom scores, reducing exacerbation rates, and minimizing hospitalizations, as evidenced by high-quality studies such as 1 and 1.

Key Points

• Inhaled corticosteroids are the cornerstone of asthma treatment, effectively controlling inflammation in the airways.
• Common medications include fluticasone (Flovent), budesonide (Pulmicort), beclomethasone (QVAR), mometasone (Asmanex), and ciclesonide (Alvesco).
• Typical adult dosing ranges from low to high strength depending on asthma severity, with fluticasone commonly prescribed at 88-220 mcg twice daily for mild to moderate asthma.
• Proper technique is crucial: shake the inhaler, exhale completely, place the mouthpiece in your mouth with a good seal, inhale slowly and deeply while activating the inhaler, hold your breath for 10 seconds, then exhale slowly.
• Always rinse your mouth after use to prevent thrush.
• Inhaled steroids work by reducing airway inflammation, decreasing mucus production, and preventing airway remodeling.
• They typically take 1-2 weeks for initial effects and up to 3 months for maximum benefit.
• Side effects are generally minimal when used properly but may include oral thrush, hoarseness, and cough, which can be minimized with proper technique and mouth rinsing.

Recommendations

• 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 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 beneficial 1.
• Beta-agonists could also be considered in combination with inhaled corticosteroids (ICS) 1.

Evidence

• High-quality studies, such as those published in the Journal of Allergy and Clinical Immunology and Chest, support the use of inhaled corticosteroids as the most effective long-term control medication for asthma 1.
• The evidence base supporting the step-wise treatment for asthma is very strong, with inhaled corticosteroids being the cornerstone of treatment 1.

From the FDA Drug Label

The anti-inflammatory actions of corticosteroids may contribute to their efficacy in asthma Studies in asthmatic patients have shown a favorable ratio between topical anti-inflammatory activities and systemic corticosteroid effects over a wide dose range of inhaled budesonide in a variety of formulations and delivery systems including an inhalation-driven, multi-dose dry powder inhaler and the inhalation suspension for nebulization Improvement in the control of asthma symptoms following inhalation of budesonide inhalation suspension can occur within 2 to 8 days of beginning treatment, although maximum benefit may not be achieved for 4 to 6 weeks Budesonide administered via a dry powder inhaler has been shown in various challenge models (including histamine, methacholine, sodium metabisulfite, and adenosine monophosphate) to decrease bronchial hyperresponsiveness in asthmatic patients.

The effects of inhaled corticosteroids (ICS) for asthma include:

• Anti-inflammatory actions: Contributing to their efficacy in asthma
• Rapid improvement: Control of asthma symptoms can occur within 2 to 8 days of beginning treatment
• Maximum benefit: May not be achieved for 4 to 6 weeks
• Decreased bronchial hyperresponsiveness: Shown in various challenge models 2 2

From the Research

Effects of Inhaled Corticosteroids on Asthma

• Inhaled corticosteroids (ICS) are the most effective controllers of asthma, suppressing inflammation by switching off multiple activated inflammatory genes 3, 4.
• ICS reduce airway hyperresponsiveness and control asthma symptoms, making them the first-line therapy for all patients with persistent asthma 3, 4.
• The addition of long-acting β₂-agonists to ICS further improves asthma control and is commonly given as combination inhalers, which improve compliance and control asthma at lower doses of corticosteroids 4.

Benefits of Inhaled Corticosteroids

• ICS decrease the risk of asthma exacerbations and improve lung function 3, 5.
• They prevent exacerbations and may reduce asthma mortality and the irreversible changes in airway function that occur in some patients 3.
• ICS are convenient to use and are the most cost-effective treatment currently available for long-term asthma control 3.

As-Needed Inhaled Corticosteroids

• As-needed ICS strategies, in which patients receive ICSs whenever they take their reliever inhaler, can improve asthma morbidity outcomes, particularly by reducing severe exacerbations and reducing the risk of adverse effects of oral corticosteroids 5.
• Combination ICS-formoterol in a single inhaler, ICS and short-acting beta2-agonists in separate inhalers, and combination ICS-albuterol in a single inhaler are effective as-needed ICS strategies 5.

Comparison of Inhaled Corticosteroid Therapies

• Different ICS/LABA combinations may have different features, and each may have different effects on small airway function and airway inflammation 6.
• Budesonide/formoterol Turbuhaler and fluticasone/salmeterol Diskus are two widely available formulations that have been compared in terms of their effects on small airway function and airway inflammation 6.