What are the effects of as-needed inhaled corticosteroids (ICS)?

From the Guidelines

As-needed inhaled corticosteroids can be an effective approach for managing mild asthma, with the most recent and highest quality study suggesting that patients can use medications like budesonide-formoterol (Symbicort) 160/4.5 mcg with 1-2 inhalations as needed when experiencing symptoms 1.

Key Considerations

• This approach works well for patients with mild, intermittent asthma who don't require daily controller therapy.
• When symptoms occur, taking the ICS together with a fast-acting bronchodilator provides both immediate relief and addresses the underlying inflammation.
• Patients should be instructed to use no more than 8 inhalations per day and to seek medical attention if they require frequent use (more than 2-3 times per week), as this indicates poor asthma control requiring adjustment to their treatment plan.
• Proper inhaler technique is essential for effective medication delivery, and patients should rinse their mouth after use to prevent oral thrush.

Benefits and Risks

• The benefits of ICS for patients with mild or moderate asthma occur at the low-dose to medium-dose ranges, with higher doses potentially reducing the risk of exacerbations but also increasing the risk of adverse effects 1.
• High doses of ICS used for prolonged periods may be associated with risk of posterior subcapsular cataracts or reduced bone density, and patients should be advised to use spacers or VHCs and rinse their mouth after inhalation to reduce local side effects.

Recommendations

• Use the lowest dose of ICS that maintains asthma control, and consider adding a LABA or alternative adjunctive therapy to a low or medium dose of ICS rather than using a higher dose of ICS to maintain asthma control 1.
• Evaluate the patient's inhaler technique and adherence, as well as environmental control measures, before increasing the dose.
• Consider supplements of calcium and vitamin D, particularly in perimenopausal women, and age-appropriate dietary intake of calcium and vitamin D for children.

From the FDA Drug Label

These patients should also be instructed to carry a medical identification card indicating that they may need supplementary systemic corticosteroids during periods of stress or a severe asthma attack.

The use of as-needed inhaled corticosteroids is not directly supported by the provided drug label. The label discusses the use of budesonide inhalation suspension as a maintenance treatment for asthma, and the need for patients to carry a medical identification card in case they require supplementary systemic corticosteroids during periods of stress or severe asthma attack. However, it does not provide information on the use of inhaled corticosteroids on an as-needed basis. 2

From the Research

As-Needed Inhaled Corticosteroids

• The use of as-needed inhaled corticosteroids (ICS) has been evaluated in several studies as a potential treatment option for asthma patients 3, 4, 5, 6.
• A study published in 2004 found that budesonide/formoterol maintenance and reliever therapy was effective in reducing the risk of severe asthma exacerbations and improving daily asthma control in patients with moderate to severe persistent asthma 3.
• Another study published in 2008 found that budesonide/formoterol maintenance and reliever therapy was associated with a 21-39% reduction in severe exacerbations compared to conventional regimens using a short-acting beta(2)-adrenoceptor agonist alone as reliever therapy 4.
• A 2021 review found that ICS-containing reliever medication was superior to short-acting beta(2)-agonist (SABA) as reliever alone, and was equivalent to maintenance ICS and SABA as reliever, in reducing the risk of severe asthma exacerbations in mild asthma patients 5.
• The 2025 guidelines for the prevention and management of bronchial asthma recommend as-needed low-dose ICS-formoterol as the first-line treatment for patients with mild asthma, and suggest that it can reduce moderate-to-severe exacerbations compared to SABA monotherapy 7.

Benefits and Risks

• The use of as-needed ICS has been shown to be effective in reducing the risk of severe asthma exacerbations and improving daily asthma control 3, 4, 5, 6.
• As-needed ICS may also reduce the overall steroid load and improve patient adherence to treatment 4, 6.
• However, the long-term safety of high-dose ICS therapy has been raised as a concern, with potential risks including osteoporosis, suppression of the hypothalamic-pituitary-adrenal axis, and increased risk of pneumonia 7.

Treatment Recommendations

• The 2025 guidelines recommend as-needed low-dose ICS-formoterol as the first-line treatment for patients with mild asthma, and suggest that it can reduce moderate-to-severe exacerbations compared to SABA monotherapy 7.
• For patients with moderate to severe asthma, the guidelines recommend the use of ICS-long-acting β2-agonists (LABA) as the preferred treatment option, due to their synergistic anti-inflammatory and anti-asthmatic effects 7.
• The guidelines also recommend the use of triple combination inhalers for patients with uncontrolled asthma despite medium- or high-dose ICS-LABA therapy 7.