What are some inhaled corticosteroids (ICS) for asthma prevention?

Inhaled Corticosteroids for Asthma Prevention

For asthma prevention, inhaled corticosteroids (ICS) are the most effective first-line controller medications and should be prescribed to all patients with persistent asthma, with specific agents including beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone, mometasone, and triamcinolone. 1

Available ICS Medications

The following inhaled corticosteroids are FDA-approved and guideline-recommended for asthma prevention:

Single-Agent ICS Options

• Beclomethasone dipropionate: Available in metered-dose inhalers (MDIs) with both chlorofluorocarbon (CFC) and hydrofluoroalkane (HFA) propellants 1
• Budesonide: Available in dry powder inhaler (DPI) formulations and has established safety and efficacy in patients as young as 6 years 2
• Ciclesonide: A newer ICS with potential for fewer local side effects due to its unique pharmacology 1
• Flunisolide: Available in MDI formulation 1
• Fluticasone propionate: Available in both DPI and MDI formulations, with established efficacy in patients 4 years and older 3
• Mometasone: Available in DPI formulation 1
• Triamcinolone acetonide: Available in MDI formulation 1

Combination ICS/LABA Products

For moderate to severe persistent asthma, combination inhalers containing both ICS and long-acting beta-agonists (LABAs) are preferred:

• Budesonide/formoterol (Symbicort): Available in 80/4.5 mcg and 160/4.5 mcg strengths, approved for patients 6 years and older 2
• Fluticasone/salmeterol (Advair): Available in multiple strengths including 100/50 mcg for children 4-11 years 3

Stepwise Approach Based on Asthma Severity

Mild Intermittent Asthma (Step 1)

• As-needed low-dose ICS-formoterol is the preferred treatment 1
• No daily controller medication is required, but short courses of oral corticosteroids may be needed for severe exacerbations 4

Mild Persistent Asthma (Step 2)

• Low-dose ICS is the preferred controller treatment 4, 1
• Alternative options include cromolyn, leukotriene modifiers, or nedocromil, though these are less effective than ICS 4
• As-needed low-dose ICS-formoterol is also an acceptable option 1

Moderate Persistent Asthma (Step 3)

• Low-dose ICS plus long-acting beta-agonist (LABA) is the preferred treatment 4, 1
• Alternative: Medium-dose ICS alone 4
• LABAs should never be used as monotherapy—they must always be combined with ICS to avoid increased risk of exacerbations and death 1, 5

Severe Persistent Asthma (Step 4)

• High-dose ICS plus LABA is the preferred treatment 4, 1
• Oral corticosteroids may be needed as add-on therapy 4
• Consider biologics like omalizumab for patients ≥12 years with inadequate control despite high-dose ICS/LABA 1

Critical Clinical Considerations

Delivery Device Selection

• MDIs with spacers or valved holding chambers improve drug delivery, particularly beneficial for children and elderly patients 1
• Dry powder inhalers (DPIs) require sufficient inspiratory flow and may not be suitable for children under 4 years 1
• Breath-actuated MDIs are useful for patients unable to coordinate inhalation and actuation 1

Monitoring and Safety

• Verify proper inhaler technique at every visit—this is the most common cause of treatment failure 5
• Monitor growth velocity in children and adolescents receiving ICS, as these medications can reduce growth by approximately 1 cm per year 2, 3
• Use spacers and rinse mouth after use to minimize local side effects including oral candidiasis, hoarseness, and dysphonia 1
• Titrate to the lowest effective dose to minimize systemic effects while maintaining asthma control 2, 3

Common Pitfalls to Avoid

• Never discontinue ICS when adding LABA in patients already on combination therapy—this increases exacerbation risk 4, 6
• Do not use nebulizers for stable asthma—they offer no therapeutic advantage over properly used MDIs with spacers 6
• Avoid chronic oral corticosteroids for poor control—instead, adjust maintenance ICS therapy 6
• Monitor for increased SABA use—needing short-acting beta-agonists more than 2-3 times daily or using more than one canister per month indicates inadequate control and need for step-up therapy 4, 5

Hepatic and Renal Impairment

• Patients with hepatic disease require close monitoring as both ICS and LABAs are predominantly cleared by hepatic metabolism, potentially leading to drug accumulation 2, 3
• No specific dosage adjustments are established for renal impairment 2, 3

Evidence Supporting ICS Efficacy

ICS are the only asthma medications that suppress airway inflammation by inhibiting inflammatory cell migration, blocking late-phase allergic reactions, and reducing airway hyperresponsiveness 1, 7. Regular use of ICS, even at low doses, prevents up to 80% of asthma hospitalizations and significantly reduces asthma mortality 8. They improve lung function, control symptoms, reduce exacerbations, and may prevent irreversible airway changes 7, 9.