What is the most effective inhaled corticosteroid (ICS) for managing severe persistent asthma in adults?

From the Guidelines

For severe persistent asthma in adults, high-dose inhaled corticosteroids (ICS) such as fluticasone propionate are recommended, with a typical dose of 500-1000 mcg twice daily via a dry powder inhaler or metered-dose inhaler, in combination with a long-acting beta-agonist (LABA) like salmeterol or formoterol. The choice of ICS should be based on the patient's response and the medication's ability to minimize side effects 1. Budesonide (Pulmicort) at 800-1600 mcg daily in divided doses is another excellent option, which can be used in combination with a LABA like formoterol in a combination inhaler like Symbicort (budesonide/formoterol) 1.

Key Considerations

• Inhaled corticosteroids are the most potent and consistently effective long-term control medication for asthma, reducing airway inflammation, decreasing mucus production, and preventing airway remodeling 1.
• Long-acting beta-agonists are not recommended for use as monotherapy for long-term control of persistent asthma, but are used as an adjunct to inhaled corticosteroid therapy for providing long-term control of symptoms 1.
• The use of a spacer device with metered-dose inhalers can improve lung deposition and reduce oral thrush, and patients should rinse their mouth after each use to minimize side effects 1.
• Regular follow-up with a healthcare provider is essential to monitor response and adjust therapy as needed, with consideration of additional controllers such as a long-acting muscarinic antagonist (LAMA) like tiotropium (Spiriva Respimat) for severe asthma 1.

Treatment Approach

• High-dose inhaled corticosteroids should be used in combination with a LABA for severe persistent asthma, with the goal of achieving and maintaining control of symptoms and reducing the risk of exacerbations 1.
• The choice of ICS and LABA should be based on the patient's response, the medication's ability to minimize side effects, and the patient's preferences and ability to use the inhaler correctly 1.
• Regular monitoring of asthma control, including symptoms, lung function, and quality of life, is essential to adjust therapy as needed and to minimize the risk of exacerbations and side effects 1.

From the Research

Inhaled Steroids for Severe Persistent Asthma in Adults

• The study 2 compared mometasone furoate and fluticasone propionate in adults with moderate-to-severe persistent asthma, finding that mometasone furoate was therapeutically equivalent to fluticasone propionate.
• Another study 3 found that fluticasone propionate was more effective than leukotriene receptor antagonists as initial maintenance therapy for persistent asthma, producing greater improvements in lung function and asthma control.
• The review 4 compared combination fluticasone and salmeterol with fixed-dose combination budesonide and formoterol for chronic asthma in adults and children, finding no significant difference in lung function outcomes, symptoms, rescue medication, and adverse events between the two treatments.

Safety and Efficacy of Inhaled Steroids

• The study 5 found that regular treatment with formoterol and an inhaled corticosteroid versus regular treatment with salmeterol and an inhaled corticosteroid for chronic asthma resulted in low certainty of evidence for all-cause mortality and non-fatal serious adverse events.
• The review 6 discussed the diagnosis and management of severe asthma, highlighting the importance of assessing adherence to medications, confounding factors, and comorbidities, and the use of phenotyping to optimize responses to existing and new therapies.

Comparison of Inhaled Steroids

• The study 2 found that mometasone furoate 400 microg twice daily was therapeutically equivalent to fluticasone propionate 500 microg twice daily in patients with moderate-to-severe persistent asthma.
• The review 3 found that fluticasone propionate was more effective than beclomethasone dipropionate in improving lung function and symptom scores in adults with persistent asthma.
• The study 5 found that formoterol and budesonide had a similar safety profile to salmeterol and fluticasone in adults and children with asthma.