Intermittent Asthma and ICS Treatment
Intermittent asthma does NOT require daily inhaled corticosteroid (ICS) therapy—SABA as-needed is appropriate for true intermittent asthma, but any patient requiring SABA more than twice weekly should be started on ICS controller therapy. 1, 2
Defining True Intermittent Asthma
The critical distinction lies in accurately classifying asthma severity:
- True intermittent asthma is characterized by symptoms less than twice weekly, nighttime awakenings less than twice monthly, and no interference with normal activities 1
- For intermittent asthma only: No controller treatment is needed; occasional severe exacerbations should be treated with a short course of oral corticosteroids 1
- SABA use more than twice weekly for symptom relief indicates persistent asthma, not intermittent asthma, and mandates initiation of ICS controller therapy 3, 2
The Paradigm Shift: When ICS IS Required
The 2020 NAEPP guidelines introduced a major change for mild persistent asthma (not intermittent asthma):
For Adults and Adolescents ≥12 Years with Mild Persistent Asthma:
The Expert Panel conditionally recommends either of these approaches 1:
- Daily low-dose ICS (200-250 μg/day beclomethasone equivalent) plus as-needed SABA 3
- As-needed ICS-SABA used concomitantly (2-4 puffs albuterol followed by 80-250 μg beclomethasone equivalent every 4 hours as needed) 1
Key evidence: These two approaches showed no differences in asthma control, quality of life, or exacerbation frequency with moderate certainty of evidence 1
Critical Caveat for As-Needed ICS Approach:
Patients with poor symptom perception are NOT good candidates for as-needed ICS therapy 1:
- Those with low symptom perception risk ICS undertreatment
- Those with high symptom perception risk ICS overtreatment
- Regular daily low-dose ICS is preferred for these patients 1
Evidence Supporting ICS in Persistent (Not Intermittent) Asthma
ICS are the most effective single long-term controller medication for persistent asthma 3, 2:
- Reduce exacerbations requiring systemic steroids by 55% compared to SABA alone (OR 0.45,95% CI 0.34-0.60) 4
- Reduce hospital admissions/ED visits by 65% (OR 0.35,95% CI 0.20-0.60) 4
- Suppress airway inflammation and prevent irreversible airway changes 5
Algorithmic Approach to Decision-Making
Step 1: Accurately classify asthma severity
- If symptoms <2 days/week AND nighttime awakenings <2 times/month → Intermittent asthma → SABA as-needed only 1, 2
- If symptoms ≥2 days/week OR nighttime awakenings ≥2 times/month → Persistent asthma → ICS required 1, 2
Step 2: For persistent asthma in patients ≥12 years, choose ICS strategy 1:
- Good symptom perception → Either daily low-dose ICS OR as-needed ICS-SABA concomitantly
- Poor symptom perception → Daily low-dose ICS (avoid as-needed approach) 1
Step 3: For children 5-11 years with persistent asthma 1:
- Daily low-dose ICS is recommended
- Insufficient evidence for as-needed ICS approach in this age group 1
Step 4: For children 0-4 years with recurrent wheezing 1:
- Conditional recommendation for short ICS courses (7-10 days) starting at onset of respiratory tract infection
- Reduces exacerbations by 33% compared to SABA alone 1
Common Pitfalls to Avoid
Do not confuse intermittent with mild persistent asthma 2:
- Patients using SABA more than twice weekly have persistent asthma and need controller therapy
- Failure to recognize this leads to undertreatment and increased exacerbation risk 3, 2
Do not use LABA as monotherapy 2, 6:
- LABA without ICS increases risk of asthma-related death and hospitalizations 2, 6
- Always combine LABA with ICS if stepping up therapy 2
Do not delay ICS initiation in persistent asthma 2:
- Early intervention with ICS improves long-term outcomes
- Prevents irreversible airway remodeling 5
For as-needed ICS-SABA approach, ensure proper patient selection 1:
- Requires adequate symptom perception
- Needs regular follow-up to ensure regimen remains appropriate 1