What is the recommended use of steroids, specifically inhaled corticosteroids (ICS), in adults with bronchial asthma according to the current Global Initiative for Asthma (GINA) 2025 guidelines?

Steroid Use in Adult Bronchial Asthma: GINA 2025 Guidelines

Primary Recommendation for Reliever Therapy

All adults with asthma should receive an inhaled corticosteroid (ICS) with every reliever medication use, either as a combination ICS-formoterol inhaler or as separate ICS taken whenever a short-acting beta-agonist (SABA) is used—SABA alone is no longer recommended as monotherapy. 1, 2, 3

• As-needed low-dose ICS-formoterol is now the preferred reliever therapy for all asthma severity levels, replacing SABA-only approaches 1, 3
• This represents a fundamental shift from traditional stepwise approaches that allowed SABA monotherapy 1
• The alternative strategy is concomitant ICS with SABA use, which has equal preference to daily low-dose ICS in patients ≥12 years with mild persistent asthma 1

Maintenance Therapy Algorithm

Step 1 (Minimal Symptoms)

• For patients with occasional transient daytime symptoms (<2 times/month, lasting hours), no nocturnal symptoms, and FEV1 >80% predicted: use as-needed low-dose ICS-formoterol only 4

Step 2 (Mild Persistent Asthma)

• Start with low to medium doses of ICS (up to 800 µg/day beclomethasone equivalent) 2, 5
• High starting doses provide no additional clinical benefit in most efficacy parameters 2, 5
• As-needed low-dose ICS-formoterol significantly reduces moderate-to-severe exacerbations compared with SABA monotherapy 4

Step 3-4 (Moderate to Severe Asthma)

• Add a long-acting beta-agonist (LABA) to low-medium dose ICS rather than increasing ICS dose alone 2
• ICS-LABA combination demonstrates synergistic anti-inflammatory effects equivalent to or better than doubling the ICS dose 4
• ICS/formoterol as both maintenance and reliever therapy (SMART strategy) is the preferred modality for patients ≥5 years old 1
• This approach allows control at lower ICS doses and improves adherence 2, 4

Step 5 (Severe Uncontrolled Asthma)

• Add triple therapy: ICS-LABA plus long-acting muscarinic antagonist (LAMA) to improve symptoms, lung function, and reduce exacerbations 1, 4
• Consider biologic therapy for severe type 2 asthma (elevated blood/sputum eosinophils ≥150/μl, and/or FeNO ≥35 ppb, and/or atopy) 4
• Low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) may be added only as a last resort 4

Critical Dosing Considerations

ICS Dose Ranges

• Low-to-medium doses are effective for most patients when combined with proper inhaler technique and spacer devices 2, 5
• If symptoms persist on standard doses, increase up to 2000 µg/day beclomethasone equivalent maximum 2
• Do NOT increase ICS dose during exacerbations in patients >4 years old who are already adherent to daily ICS—this strategy is not recommended 1

Safety Profile by Dose

• Long-term ICS at recommended clinical doses is safe 4
• Prolonged high-dose ICS (>800 µg/day beclomethasone equivalent) may cause systemic adverse effects including osteoporosis, hypothalamic-pituitary-adrenal axis suppression, and increased pneumonia risk 6, 4
• Number needed to harm at 12 months for ICS 201-599 µg: pneumonia=230, cardiovascular events=473 6
• Number needed to harm at 12 months for ICS ≥600 µg: pneumonia=93, cardiovascular events=224 6

Acute Exacerbation Management

• Use oral prednisolone 30-40 mg daily (or 40-60 mg for moderate-to-severe exacerbations) until lung function returns to previous best 1, 4
• Seven days treatment is usually sufficient, though may continue up to 21 days 1
• Oral steroids given by mouth—intravenous administration offers no advantages 1
• Short courses up to 2 weeks do not require tapering; stop from full dosage 1
• For patients using budesonide-formoterol as maintenance, take 1-2 additional inhalations during early mild-to-moderate exacerbations (maximum 8 inhalations daily) 4

Monitoring and Dose Adjustment

• Schedule follow-up every 2-4 weeks after initial therapy, then every 1-3 months if responding 4
• Allow 1-3 months of stability before attempting stepwise reduction 1, 2
• Decrease by 25-50% at each step-down 2
• Trigger for treatment escalation: SABA use more than 2-3 times daily or poor symptom control 1, 2

Common Pitfalls to Avoid

Inhaler Technique

• Verify proper inhaler technique before escalating therapy—inadequate delivery is a common cause of treatment failure 2, 7
• Use large volume spacer devices with metered-dose inhalers to improve effectiveness 1, 2
• Consider dry powder inhalers as first-line options for many patients 2

Adherence Issues

• Check compliance before any treatment increase 1, 2
• Regular training in correct inhaler use is essential for optimal control 4
• Poor adherence is a risk factor for asthma-related death 4

Inappropriate SABA Use

• Overuse of SABA (>1 canister salbutamol per month) is a risk factor for asthma-related death 4
• Never prescribe SABA alone without accompanying ICS 1, 3

Special Populations and Adjunctive Therapies

Severe Asthma Refractory to Step 5

• Add low-dose azithromycin 250-500 mg three times weekly for 26-48 weeks to reduce exacerbations 4
• Consider bronchial thermoplasty for adults uncontrolled despite optimized treatment when biologics are unavailable or inappropriate 4

Cough Variant Asthma

• Treatment principles are identical to typical asthma 4
• ICS-LABA is first choice, used for >8 weeks 4
• For poor responders with severe airway inflammation, add leukotriene receptor antagonist or short-term oral corticosteroids (10-20 mg/day for 3-5 days) 4

Immunotherapy Considerations

• Subcutaneous immunotherapy may reduce required ICS dosage and improve quality of life in adults 4
• House dust mite sublingual immunotherapy may be added for sensitized patients with FEV1 >70% predicted if symptoms persist despite low-to-medium dose ICS therapy 4