Inhaled Corticosteroids for Persistent Asthma and COPD
Asthma: ICS as First-Line Therapy
Inhaled corticosteroids are the preferred long-term control therapy for persistent asthma in all age groups, superior to all alternative medications including leukotriene receptor antagonists, cromolyn, nedocromil, and theophylline. 1
Adults and Children ≥5 Years with Persistent Asthma
Start with low-dose ICS monotherapy for mild persistent asthma as the preferred initial treatment, demonstrating superior efficacy compared to leukotriene modifiers in improving lung function, reducing symptoms, decreasing exacerbations, and lowering hospitalization rates 1
For moderate persistent asthma, use low-dose ICS plus long-acting beta-agonist (LABA) OR medium-dose ICS alone as preferred treatment 1
For severe persistent asthma requiring step-up, add LABA to medium-dose ICS rather than increasing to high-dose ICS monotherapy, as combination therapy provides superior symptom control and exacerbation reduction with lower systemic corticosteroid exposure 1
Children Ages 1-4 Years
Initiate ICS therapy (budesonide nebulizer solution for ages 1-8 years or fluticasone DPI for ages ≥4 years) for persistent symptoms, as limited available evidence demonstrates improvements in short-term asthma control consistent with older children 1
Consider initiating long-term control therapy in infants/young children with >3 wheezing episodes in the past year lasting >1 day and affecting sleep, plus identifiable asthma risk factors 1
Critical Dosing Principles
Always use the lowest ICS dose compatible with disease control to minimize systemic effects, as most benefit occurs in the low-to-medium dose range with minimal additional improvement at higher doses 1, 2
Step down therapy after 2-4 months of good control rather than maintaining unnecessarily high doses 3, 4
Why ICS Beat the Alternatives
The evidence strongly favoring ICS over alternatives is compelling:
Leukotriene receptor antagonists are inferior: Direct comparison trials show ICS significantly outperform LTRAs on all major outcome measures in persistent asthma, making LTRAs only an alternative (not preferred) option when ICS administration is problematic 1
Cromolyn and nedocromil lack sufficient efficacy: Systematic reviews conclude insufficient evidence exists for cromolyn's beneficial effect, and nedocromil shows no difference from placebo on most outcomes despite reducing urgent care visits 1
LABA monotherapy is dangerous in asthma: Switching from ICS to LABA alone increases treatment failures (24% vs 6%) and exacerbations (20% vs 7%), and increases risk of asthma-related deaths 1, 5
COPD: ICS Role More Limited
In COPD, ICS-containing therapy should be reserved for patients with frequent or severe exacerbations (≥2 moderate exacerbations or ≥1 severe exacerbation requiring hospitalization per year) and elevated blood eosinophils, representing approximately 10% of the COPD population. 6
When to Use ICS in COPD
Prescribe ICS/LABA combination (e.g., fluticasone/salmeterol 250/50 mcg twice daily) for symptomatic COPD patients with exacerbation history, as this reduces exacerbations by approximately 25%, improves quality of life, and attenuates yearly decline in lung function 5, 7, 8
Consider triple therapy (ICS/LABA/LAMA) for patients with persistent exacerbations despite dual bronchodilator therapy, particularly those with blood eosinophils ≥300 cells/μL or concomitant asthma 8, 6
When NOT to Use ICS in COPD
Avoid ICS in stable COPD patients with infrequent exacerbations (<2 per year), as dual bronchodilation alone provides better outcomes without pneumonia risk in this population 6
Do not use ICS monotherapy in COPD, as initial studies showed no effect on pulmonary function decline despite some symptom improvement 2, 8
COPD-Specific Safety Concerns
ICS increase pneumonia risk in COPD patients, particularly with advanced age and worse disease severity, though risk estimates vary substantially by study design and specific ICS used 8, 6
Current evidence does NOT support mortality benefit from ICS in COPD, as regulatory agencies (EMA and FDA) have rejected mortality benefit claims from recent trials 6
Universal Safety Considerations
Local Effects (Manageable)
Oral candidiasis occurs primarily with higher doses: Prevent by rinsing mouth after each use, using spacers with MDIs, and ensuring proper inhaler technique 1, 5
Dysphonia and hoarseness are common: Address with proper technique and spacer use 1, 5
Systemic Effects (Dose-Dependent)
Clinically significant adrenal suppression is rare at low-to-medium doses but increases with high-dose ICS; consider morning plasma cortisol or 24-hour urinary cortisol testing if clinical concern exists 3
Bone densitometry is recommended only for patients on high-dose ICS >1 year or receiving frequent oral corticosteroid courses, particularly perimenopausal women 3
Posterior subcapsular cataracts warrant slit-lamp examination for patients on high-dose ICS >1 year 3
Monitor growth in pediatric patients, as younger children may receive higher mg/kg doses and face greater risk for systemic effects 1, 2
Critical Pitfalls to Avoid
Never discontinue ICS abruptly in moderate-to-severe asthma, as this dramatically increases exacerbation risk 3
Never use LABA without ICS in asthma patients, as LABA monotherapy increases asthma-related deaths 1, 5, 7
Do not prescribe ICS to 50-80% of COPD patients currently receiving them inappropriately, as observational data shows massive ICS overuse in patients not meeting guideline criteria, exposing them to pneumonia risk without benefit 6
Do not delay stepping down therapy in well-controlled patients, as it is as important to reduce medication in stable disease as to increase it in uncontrolled disease 3
Verify proper inhaler technique at every visit, as poor technique is a major cause of apparent treatment failure 4