What is the recommended dosage and treatment regimen for Inhaled Corticosteroids (ICS) in asthma management?

Inhaled Corticosteroid (ICS) Dosage and Treatment Regimen for Asthma Management

The recommended dosage and treatment regimen for Inhaled Corticosteroids (ICS) in asthma management should be tailored according to asthma severity, with low-dose ICS as the preferred controller treatment for mild persistent asthma, medium-dose ICS for moderate persistent asthma, and high-dose ICS for severe persistent asthma. 1

Stepwise Approach Based on Asthma Severity

Mild Intermittent Asthma

• No controller treatment needed; only short-acting beta-agonists (SABA) as needed for symptom relief 1
• Occasional severe exacerbations should be treated with a short course of oral corticosteroids 1

Mild Persistent Asthma (Step 2)

• Preferred treatment: Low-dose inhaled corticosteroids with as-needed SABA 1
• Alternative options: Leukotriene receptor antagonists, cromolyn, nedocromil, or theophylline 1
• For patients ≥12 years, either daily low-dose ICS or as-needed ICS with SABA used concomitantly is acceptable 1
• Starting dose for adults previously on bronchodilators alone: 0.5 mg once daily or 0.25 mg twice daily (budesonide) 2

Moderate Persistent Asthma (Step 3-4)

• Preferred treatment: Low-dose ICS plus long-acting beta-agonist (LABA) or medium-dose ICS 1
• Alternative: Medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 1
• Starting dose for adults previously on ICS: 0.5 mg once daily or 0.25 mg twice daily up to 0.5 mg twice daily (budesonide) 2

Severe Persistent Asthma (Step 5-6)

• Preferred treatment: High-dose ICS plus LABA 1
• May require addition of oral corticosteroids 1
• Starting dose for adults previously on oral corticosteroids: 0.5 mg twice daily (budesonide) 2

Dosing Considerations

ICS Efficacy and Dose-Response

• ICS are the most effective controllers of asthma, suppressing inflammation by switching off activated inflammatory genes 3
• The dose-response curve for ICS is relatively flat, with 80-90% of maximum benefit achieved at low to medium doses 4
• For patients not adequately controlled on low-dose ICS, adding a LABA is often more effective than increasing the ICS dose 5, 6

Age-Specific Considerations

• For children 12 months to 8 years: Budesonide inhalation suspension is indicated for maintenance treatment 2
• For symptomatic children not responding to non-steroidal therapy: Starting dose of 0.25 mg once daily may be considered 2
• For children 5-11 years: Treatment should promote active participation in physical activities 1
• For patients ≥12 years: Follow adult dosing guidelines with appropriate adjustments 1

Monitoring and Adjustment

• Assess control regularly and adjust treatment accordingly 1
• Step up if needed (after checking adherence, inhaler technique, environmental factors, and comorbidities) 1
• Step down if asthma is well-controlled for at least 3 consecutive months 1
• Monitor growth in pediatric patients 1

Administration and Delivery Devices

• For budesonide inhalation suspension: Use via compressed air-driven jet nebulizers only (not for ultrasonic devices) 2
• When using metered dose inhalers (MDIs), spacers (valved holding chambers) markedly increase lung deposition 1
• Dry powder inhalers (DPIs) and hydrofluoroalkane-propelled MDIs provide equivalent bronchoprotective effects 1

Common Pitfalls and Caveats

• ICS are not indicated for relief of acute bronchospasm - use SABA instead 2
• Systemic effects of ICS may occur but are typically not clinically important except with long-term high-dose use 1, 3
• Potential side effects include oral candidiasis (thrush) - advise patients to rinse mouth after inhalation 2
• Some patients may have reduced responsiveness to ICS, including smokers and certain ethnic populations 1
• Compliance with guidelines by physicians and patients is often poor despite evidence that following guidelines improves quality of life and reduces emergency visits 1
• When transferring patients from oral corticosteroids to ICS, taper oral steroids slowly to avoid adrenal suppression 2
• Regular use of low-dose ICS in mild asthma can lead to further reduction in airway responsiveness and maintain normal sputum eosinophil counts 7