What is the recommended first-line treatment for persistent asthma using inhaled corticosteroids (ICS)?

First-Line Treatment for Persistent Asthma: Inhaled Corticosteroids

Inhaled corticosteroids (ICS) are the preferred first-line controller medication for persistent asthma in all age groups due to their superior effectiveness in controlling airway inflammation compared to any other single long-term control medication. 1, 2

Why ICS is the First Choice

• ICS effectively suppress airway inflammation, which is the underlying pathophysiological mechanism of persistent asthma
• When used consistently, ICS improve asthma control more effectively than any other single long-term control medication 2
• ICS therapy has been shown to:
  • Reduce asthma symptoms
  • Improve lung function
  • Prevent exacerbations
  • Potentially reduce asthma mortality
  • Prevent irreversible airway changes 3

Initial Dosing Recommendations

For Adults and Children ≥12 years:

• Start with low-dose ICS for mild persistent asthma 1
• Examples of low-dose ICS include:
  • Beclomethasone HFA: 80-240 mcg daily
  • Budesonide DPI: 180-600 mcg daily
  • Mometasone DPI: 200 mcg daily
  • Fluticasone propionate: 88-250 mcg daily 1

For Children 5-11 years:

• Low-dose ICS via appropriate delivery device (nebulizer, MDI with holding chamber with/without face mask, or DPI) 2

For Children <5 years:

• Low-dose ICS via nebulizer or MDI with holding chamber and face mask 2
• Budesonide nebulizer solution is FDA-approved for children 1-8 years 2

Monitoring Response to Therapy

After initiating ICS therapy, assess control using these criteria:

• Symptoms ≤2 days/week
• Nighttime awakenings ≤2 times/month
• No interference with normal activity
• SABA use ≤2 days/week 1

Schedule follow-up in 2-6 weeks to assess response. Increasing use of rescue short-acting beta agonists (>2 days/week) indicates inadequate control and need for therapy adjustment 1.

Step-Up Therapy When Control is Not Achieved

If asthma remains uncontrolled after initiating low-dose ICS:

1. Preferred next step: Add a long-acting beta-agonist (LABA) to low-dose ICS 1, 2

   • This combination is more effective than increasing ICS dose alone
   • LABAs should NEVER be used as monotherapy due to safety concerns 1

2. Alternative options (if LABA not appropriate):

   • Increase ICS dose to medium-dose range
   • Add a leukotriene receptor antagonist (LTRA) to low-dose ICS
   • Add theophylline to low-dose ICS 2, 1

Important Safety Considerations

• Low-dose ICS therapy has minimal systemic effects 1, 4
• Higher doses may have transient effects on cortisol production 1
• Rinsing the mouth after ICS use can reduce the risk of oral thrush 1
• Using a spacer increases the effectiveness of inhaled drugs 1

Special Populations

Children:

• ICS are the preferred controller medication for all age groups with persistent asthma 2
• For infants and young children who had >3 episodes of wheezing lasting >1 day and affecting sleep in the past year, plus risk factors for asthma development, consider initiating long-term control therapy 2

Elderly:

• Nebulized ICS may be preferable for patients with poor hand-lung coordination or low inspiratory flow rate 5

When to Consider Referral to a Specialist

Consider referral if:

• Symptoms remain uncontrolled despite Step 3 therapy
• Patient has had ≥2 exacerbations requiring oral corticosteroids in the past year
• Patient requires Step 4 care or higher
• Additional testing is needed 1

By following these evidence-based recommendations for initiating ICS therapy in persistent asthma, clinicians can effectively control symptoms, improve lung function, and reduce the risk of exacerbations in patients with asthma.