What is the recommended steroid management for asthma?

Steroid Management for Asthma

Core Principle

Inhaled corticosteroids are the most potent and consistently effective long-term control medication for asthma and should be the foundation of treatment for all patients with persistent asthma. 1

Stepwise Approach Based on Asthma Severity

Mild Intermittent Asthma

• No daily controller treatment required 1
• Use short-acting β2-agonists as needed for symptom relief 1
• For acute exacerbations: oral corticosteroids (prednisolone 30-40 mg daily) for short courses 1

Mild Persistent Asthma

• Preferred: Low-dose inhaled corticosteroids (equivalent to 200-800 µg/day beclomethasone) 1
• Alternative options (if patient cannot tolerate inhaled steroids): leukotriene receptor antagonists, cromolyn, nedocromil, or sustained-release theophylline 1
• For children <5 years: low-dose inhaled corticosteroids via nebulizer, dry powder inhaler, or metered-dose inhaler with spacer 1

Moderate Persistent Asthma

• Preferred: Low-dose inhaled corticosteroids PLUS long-acting β2-agonist 1
• Alternative: Medium-dose inhaled corticosteroids alone (up to 2000 µg/day beclomethasone equivalent) 1
• Critical warning: Long-acting β2-agonists should NEVER be used as monotherapy due to increased risk of exacerbations and death 1

Severe Persistent Asthma

• High-dose inhaled corticosteroids (up to 2000 µg/day beclomethasone equivalent) PLUS long-acting β2-agonist 1
• Consider adding leukotriene receptor antagonist or theophylline as third-line agent 1
• Oral corticosteroids may be required for maintenance in the most severe cases 1
• Consider omalizumab for patients with allergic asthma inadequately controlled on high-dose therapy 2

Acute Exacerbations

Moderate to Severe Exacerbations

• Oral systemic corticosteroids are mandatory 1
• Dosing:
  • Adults: Prednisolone 30-60 mg daily for 5-10 days 1
  • Children: 1-2 mg/kg/day for 3-10 days 1
  • Alternative: IV hydrocortisone 200 mg every 6 hours for severely ill patients 1
• Route: Oral administration is equally effective as IV and should be preferred 1
• Tapering is NOT necessary for short courses up to 2 weeks; can stop abruptly from full dose 1

Life-Threatening Features

• Immediate high-dose systemic steroids (prednisolone 30-60 mg OR IV hydrocortisone 200 mg) 1
• Continue every 6 hours until clinical improvement 1

Delivery Device Optimization

Metered-Dose Inhalers

• Always use with spacer devices (valved holding chambers) to markedly increase lung deposition from 20-30% to much higher levels 1
• Spacers are particularly critical for children and patients with poor technique 1

Device Selection Algorithm

1. Start with metered-dose inhaler plus spacer 1
2. If patient cannot manage spacer bulk during daytime, switch to dry powder inhaler or breath-actuated device 1
3. For children <5 years: nebulizer, dry powder inhaler, or metered-dose inhaler with spacer ± face mask 1

Dose Titration Principles

Stepping Up Treatment

• Trigger for intensification: short-acting β2-agonist use >2 days/week (excluding exercise prophylaxis) or >2 nights/month 1
• Before increasing dose, verify adherence and proper inhaler technique 1
• When inadequately controlled on low-dose inhaled corticosteroids, give equal weight to either increasing steroid dose OR adding long-acting β2-agonist 1

Stepping Down Treatment

• Require 1-3 months of stability before dose reduction 1
• Decrease dose by 25-50% at each step 1
• Monitor closely for loss of control during reduction phase 1

Special Populations

Children 6 to <12 Years

• Inhaled corticosteroids (≥200 mcg/day fluticasone equivalent) are first-line for persistent asthma 2
• Demonstrated reduction in exacerbation rates (rate ratio 0.69 at 24 weeks, 0.57 at 52 weeks) 2
• Long-acting β2-agonists are NOT the preferred adjunctive therapy in this age group (unlike adults ≥12 years) 1

Smokers

• Decreased responsiveness to corticosteroids due to persistent irritation and altered inflammatory pathways 1
• May require higher doses or alternative anti-inflammatory strategies 1

Black Patients

• Potential genetic variations in β2-adrenergic receptors may reduce long-acting β2-agonist effectiveness 1
• Children may have increased risk of corticosteroid insensitivity due to T-cell pathway deficiencies 1

Monitoring Requirements

Indicators of Adequate Control

• Minimal or no chronic symptoms 1
• No limitation of activities 1
• Minimal need for short-acting β2-agonists (<2 days/week) 1
• Maintenance of personal best pulmonary function (FEV1 or PEF ≥80% predicted) 1
• Minimal or no exacerbations 1

Objective Measurements

• Peak expiratory flow or FEV1 monitoring is essential, analogous to glucose monitoring in diabetes 1
• Validated questionnaires (Asthma Control Test, Asthma Control Questionnaire) provide standardized assessment 1

Critical Safety Considerations

Systemic Effects of Inhaled Corticosteroids

• Generally not clinically important except with long-term high-dose use 1
• Local side effects: oral candidiasis (rinse mouth after use), dysphonia (may resolve by switching from dry powder to metered-dose inhaler with spacer) 1

Long-Acting β2-Agonist Safety

• FDA warning: increased severe exacerbations and deaths when used as monotherapy 1
• Must ALWAYS be combined with inhaled corticosteroids 1
• Consider increasing inhaled corticosteroid dose as alternative to adding long-acting β2-agonist 1

Oral Corticosteroid Risks

• Short courses produce very low rates of gastrointestinal bleeding 1
• Greatest risk in patients with history of GI bleeding or on anticoagulants 1
• Sedation is contraindicated in acute exacerbations 1

Cost-Effectiveness

• No clinically meaningful differences between various inhaled corticosteroid formulations 1
• Prescribe the cheapest inhaled corticosteroid that the patient can use correctly and that controls symptoms 1
• Inhaled corticosteroids are the most cost-effective treatment for long-term asthma control 3