What is the appropriate treatment for a patient with mild to moderate asthma using a steroid-only inhaler, such as fluticasone propionate (Flovent) or beclomethasone dipropionate (Qvar)?

Steroid-Only Inhaler for Asthma

Inhaled corticosteroids (ICS) alone are the preferred first-line controller medication for mild to moderate persistent asthma, with low-dose fluticasone propionate (100-250 mcg/day) or beclomethasone dipropionate (200-500 mcg/day) administered twice daily providing optimal control with minimal systemic effects. 1, 2

Initial Treatment Strategy

For patients with mild to moderate persistent asthma, ICS monotherapy is the most effective single long-term control medication, demonstrating superior outcomes compared to leukotriene modifiers, theophylline, or other alternatives 1, 3. Patients treated with ICS demonstrate:

• Improved symptom scores and lower exacerbation rates compared to other single controller medications 1
• Reduced need for supplemental short-acting beta-agonists (SABAs) 1
• Fewer courses of oral systemic corticosteroids and hospitalizations 1
• 80-90% of maximum therapeutic benefit achieved at low doses with minimal systemic adverse effects 4

Specific ICS Regimens

Recommended Low-Dose Options:

• Fluticasone propionate: 100-250 mcg/day (twice daily dosing) 2, 4
• Beclomethasone dipropionate: 200-500 mcg/day (twice daily dosing) 2
• Budesonide: 200-400 mcg/day (twice daily dosing) 1, 2

There are no clinically meaningful differences among various ICS types in terms of efficacy 1. However, fluticasone propionate may provide slightly greater improvements in peak expiratory flow compared to beclomethasone at equivalent doses 5.

Delivery Technique Optimization

Use a spacer or valved holding chamber with metered-dose inhalers to increase lung deposition from 20-30% to significantly higher levels and reduce oropharyngeal side effects 1, 4. Essential technique instructions include:

• Instruct patients to rinse mouth and spit after each inhalation to minimize oral candidiasis and dysphonia 4
• Verify proper inhaler technique before considering dose escalation, as poor technique is a common cause of apparent treatment failure 2

When ICS Monotherapy Is Insufficient

If asthma remains uncontrolled after 2-6 weeks on low-dose ICS, add a long-acting beta-agonist (LABA) rather than increasing ICS dose alone 1, 2, 4. This combination provides:

• Greater improvement in lung function, symptoms, and exacerbation reduction compared to doubling or quadrupling ICS dose 1, 4
• Better asthma control with lower total steroid exposure 6, 7

Critical Safety Warning:

LABAs must NEVER be used as monotherapy for asthma, as this increases risk of severe exacerbations and asthma-related deaths 1, 2, 4. LABAs must always be combined with ICS in a single inhaler or as separate inhalers 2, 4.

Monitoring for Inadequate Control

SABA use more than 2 days per week for symptom relief (excluding exercise prevention) indicates inadequate control and the need to intensify anti-inflammatory therapy 1, 3. This is one of the most important warning signs requiring treatment escalation 1.

Alternative Approaches for Mild Persistent Asthma

For patients ≥12 years with adherence concerns to daily therapy, as-needed low-dose ICS plus SABA used concomitantly during symptom worsening is an acceptable alternative to daily low-dose ICS 2, 4. However, this approach provides similar but not superior outcomes to regular daily ICS 1.

Step-Down Strategy

Once asthma control is sustained for 2-4 months, step down therapy to the minimum dose required to maintain control 2, 4. Continue monitoring for at least 3 months of stable control before considering further dose reduction 2, 4.

Common Pitfalls to Avoid

• Do not start with high-dose ICS, as it provides no clinically meaningful advantage over low-dose ICS (only 5% improvement in FEV1) 2
• Do not increase ICS dose short-term for worsening symptoms in adherent patients with mild-moderate asthma, as this provides no benefit 2
• Confirm medication adherence and address environmental factors before escalating ICS dose 2
• Recognize that smokers have decreased responsiveness to steroids due to persistent irritation and scarring 1
• Be aware that Black children may have increased risk of corticosteroid insensitivity due to deficiencies in T cell pathways 1

Local Side Effects Management

Common local effects include oral candidiasis, hoarseness, and dysphonia 4. These can be managed by:

• Adding a spacer device or changing the delivery system 1
• Switching from dry-powder inhaler to metered-dose inhaler with spacer 1
• Temporary cessation of medication if symptoms are severe 1