Inhaled corticosteroids (ICS) have been shown in small randomized controlled trials (RCTs) to provide benefit in asthma management in terms of reducing hospital admissions compared with placebo. No consistent evidence indicates that doubling the dose of ICS improves peak expiratory flow rate (PEFR) and symptoms compared with continuing the usual dose of ICS. Use of ICS in addition to oral corticosteroids offers no benefit in preventing asthma exacerbations [Rodolfo et al, 2005]:
Increasing the ICS dose at early signs of an exacerbation does not appear to benefit management of an exacerbation:
- ICS versus placebo:
- One systematic review (search date February 2005, 10 RCTs, n = 587) in adults and children attending an emergency department showed that ICS reduced hospital admission. Subgroup analysis found that the benefit was significant only in people not receiving concomitant oral corticosteroids (OR 0.27, 95% CI 0.14 to 0.52). Treatment with ICS was well tolerated, with few reported adverse effects.
- An RCT (n = 390) showed that doubling the dose of ICS for worsening PEFR and symptoms was no better than continuing therapy with the regular dose. People at risk of exacerbation monitored their morning peak flow and symptoms for up to 12 months. They were randomly assigned to use an active inhaler or a placebo inhaler and to double the usual dose for 14 days if their PEFR or symptoms deteriorated. Results showed no difference in use of oral corticosteroids (11% vs. 12%) or symptom scores [Harrison et al, 2004].
- ICS plus oral corticosteroids versus oral corticosteroids alone:
- One systematic review (search date 2003, three RCTs, n = 909) showed that in adults attending an emergency department, relapse rates after 24 days did not differ significantly with either regimen (OR 0.68, 95% CI 0.46 to 1.02) [Rodolfo et al, 2005].
- ICS versus oral corticosteroids:
- One systematic review (search date 2001, four RCTs, 772 adults and 22 children) showed no significant difference in relapse rates at 7–10 days in people receiving oral prednisolone or ICS (equivalent to beclometasone, 2000 micrograms/day) for an acute asthma exacerbation (OR 1.00, 95% CI 0.66 to 1.52, p = 0.88). One subsequent RCT (n = 40) in adults discharged from hospital following an exacerbation showed no difference in lung function or symptoms between oral prednisolone and inhaled flunisolide at 7 days. An additional RCT (n = 413) showed no significant difference in treatment failure with oral prednisolone and high-dose inhaled fluticasone (2000 micrograms/day) in people presenting to their GP for an asthma exacerbation [Rodolfo et al, 2005].
- Further small studies have shown conflicting evidence of ICS compared with oral corticosteroids in children with acute asthma. Overall, oral corticosteroids appear to be superior to ICS, but trials are heterogeneous, making it difficult to draw definite conclusions [Schuh et al, 2006].