What is the first-line treatment for adults with Reactive Airway Disease using Inhaled Corticosteroids (ICS)?

First-Line Treatment for Adults with Reactive Airway Disease Using Inhaled Corticosteroids (ICS)

Inhaled corticosteroids (ICS) should be considered as first-line treatment for adults with Reactive Airway Disease. 1

Treatment Algorithm

Initial Treatment

• Start with inhaled corticosteroids (ICS) as the cornerstone of treatment for adults with reactive airway disease 1
• Initiate with low to medium doses of ICS, as higher starting doses have not demonstrated additional clinical benefits in most efficacy parameters but may have potential safety concerns 2
• ICS are effective on a twice daily dosing schedule 1
• Ensure proper inhaler technique and use of appropriate delivery devices; consider large volume spacers with metered-dose inhalers (MDIs) to improve drug delivery 1

If Inadequate Response to Initial ICS Treatment

• If symptoms are not controlled on standard doses, consider increasing to higher doses of inhaled steroids up to a daily equivalent of 2000 μg beclomethasone 1
• If symptoms are not controlled on twice daily dosing and there are concerns about the total daily dose, try increasing the dosage frequency to four times daily while maintaining the same total daily dose 1
• Consider adding a long-acting beta2-agonist (LABA) to low-medium dose ICS rather than further increasing the ICS dose 1
  • Strong evidence consistently indicates that adding LABAs to low-medium dose ICS improves outcomes 1
  • This combination approach may allow for control of asthma and airway inflammation at lower ICS doses 3

For Specific Symptom Patterns

• For patients with predominant overnight symptoms, consider adding salmeterol (a long-acting beta2-agonist) which produces bronchodilation for 12 hours 1
• For patients with cough as the primary symptom (cough variant asthma), ICS should be the first-line treatment 1
  • If response is incomplete, consider stepping up the ICS dose and adding a leukotriene inhibitor 1

Monitoring and Dose Adjustment

• Allow a one to three month period of stability before attempting stepwise reduction in inhaled steroids 1
• When reducing ICS, decrease the dose by 25-50% at each step 1
• Monitor for symptom control; patients requiring short-acting beta2-agonists more than two or three times daily should be maintained on or started on ICS 1

Important Considerations

• Device Selection: Consider dry powder inhalers (DPIs) as first-line options for many patients as they may be preferred over MDIs and have lower environmental impact 1
• Biomarkers: Non-invasive measurement of airway inflammation (such as fractional exhaled nitric oxide) may have clinical utility in predicting response to corticosteroids 1
• Combination Therapy: The addition of a LABA to ICS therapy is more effective than increasing the dose of ICS monotherapy when symptoms are not adequately controlled 4
• Safety: Be aware of potential adverse effects with high-dose ICS including adrenal suppression, local side effects (pharyngeal irritation, dysphonia), and increased risk of pneumonia 1

Special Cases

• For patients with refractory symptoms, consider checking for proper inhaler technique, medication adherence, and alternative diagnoses before escalating therapy 1
• In cases of acute exacerbations, oral corticosteroids should be used, with no advantage to intravenous administration 1
• For patients with non-asthmatic eosinophilic bronchitis (NAEB), ICS are also the first-choice treatment 1

By following this treatment approach, most patients with reactive airway disease should achieve good symptom control with minimized risk of adverse effects from medication.