Management of Inhaled Corticosteroids During Mild Respiratory Illness in Asthmatic Patients
Continue the patient's current inhaled corticosteroid regimen at the same dose without increasing it during a mild respiratory illness. 1
Evidence-Based Recommendation
The 2020 National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 4 provides clear guidance on this clinical scenario:
For patients ≥4 years old who are adherent to their daily ICS, increasing the ICS dose in the setting of an exacerbation is NOT recommended. 1
This conditional recommendation against dose escalation applies specifically to patients with mild to moderate persistent asthma who are likely to be adherent to daily ICS treatment. 1
Understanding the Evidence Base
The recommendation against increasing ICS doses during respiratory illness is based on controlled clinical trials where adherence to background therapy was enforced (typically 80% or more):
In children aged 4-11 years, temporarily increasing the ICS dose in response to worsening symptoms did not significantly reduce the rate of exacerbations or improve asthma quality of life. 1
A 2018 study in 254 children found no difference in the rate of exacerbations treated with systemic corticosteroids when quintupling the ICS dose at early signs of loss of asthma control, and the intervention group showed a trend toward reduced growth rate (P=0.06). 1
In individuals aged 12 years and older, the intervention did not significantly reduce exacerbations or asthma hospitalizations, with low certainty of evidence for both outcomes. 1
A 2022 Cochrane review confirmed that participants randomized to increase their ICS dose at the first signs of an exacerbation had similar odds of needing rescue oral corticosteroids compared to those randomized to a placebo inhaler (OR 0.97,95% CI 0.76 to 1.25; 8 studies; 1774 participants; moderate quality evidence). 2
Critical Caveat: The Adherence Exception
This recommendation has an important real-world exception:
The working group recommendation not to increase ICS dose applies only to patients who are adherent to their maintenance ICS therapy. 1
In the real world, adherence to ICS is usually poor, with only about 50% of patients in the United States maintaining adequate adherence. 1
For patients aged ≥16 years whose adherence to daily therapy is not assured, clinicians can consider quadrupling the regular daily dose for increased symptoms or decreased peak flow. 1
What Patients Should Actually Do During Mild Respiratory Illness
Instead of increasing ICS doses, the appropriate management includes:
Continue the current maintenance ICS regimen without dose adjustment. 1
Use short-acting beta-agonist (SABA) as needed for symptom relief. 3, 4
For patients on ICS-formoterol maintenance and reliever therapy (SMART), continue using as-needed ICS-formoterol for symptom relief. 1
Monitor for signs of worsening that would require systemic corticosteroids: inability to control symptoms with increased SABA use, worsening peak flow measurements, or development of severe symptoms. 1
Common Pitfalls to Avoid
Do not instruct adherent patients to double or quadruple their ICS dose at the first sign of deterioration unless you have documented evidence of poor adherence to maintenance therapy. 1
Do not confuse this recommendation with the separate strategy of as-needed ICS-formoterol, which is a different treatment approach where patients use combination ICS-formoterol as both maintenance and reliever therapy. 1, 5, 6
Do not apply this recommendation to children under 4 years old with recurrent wheezing, where a short course of ICS (in addition to SABA) at the onset of respiratory illness is conditionally recommended. 1
When to Escalate to Systemic Corticosteroids
Rather than increasing ICS doses, consider oral corticosteroids if: