Clinical Question

Does patient-initiated home management of asthma exacerbations with increased doses of inhaled corticosteroids (ICSs) reduce the need for further intervention compared with a daily maintenance dosage of an ICS among children and adults with mild to moderate persistent asthma?

Evidence-Based Answer

In this Cochrane review, patients with mild to moderate persistent asthma and symptoms consistent with an acute asthma exacerbation who are treated with increased doses of ICSs show no reduction in the need for further intervention with primarily systemic corticosteroids vs. patients treated with stable doses of ICSs. Similarly, increased doses of ICSs do not reduce unscheduled visits to physicians, acute care facilities, or emergency departments or hospital admissions compared with stable doses of ICSs.¹ (Strength of Recommendation: B, inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Asthma is a leading cause of morbidity and mortality related to chronic respiratory disease; it affects 272 million people worldwide.^2,3 Early recognition and management of asthma exacerbations are essential in reducing morbidity, mortality, and health care costs associated with asthma. Asthma action plans, which are written, patient-initiated, home management guidelines that describe maintenance therapy and steps for treatment escalation during an exacerbation, decrease the severity and duration of asthma exacerbations.¹ ICSs are a mainstay of asthma action plans, and the Global Initiative for Asthma (GINA) guideline recommends increased ICS dosing during an asthma exacerbation.⁴

The authors of the Cochrane review sought to determine the safety and effectiveness of increased ICS dosing as part of patient-initiated home management in children and adults with mild to moderate persistent asthma.¹ Asthma exacerbations required systemic corticosteroids or unscheduled medical attention, including unscheduled physician visits, urgent care and emergency department visits, and hospital admissions. The review included nine double-blinded, randomized controlled trials of participants with mild to moderate persistent asthma from North America, Europe, Australia, and New Zealand between 1998 and 2018; five trials included patients 15 years and older (n = 1,247), and four included children younger than 15 years (n = 676).¹ The primary outcome was treatment failure, defined as patients requiring rescue systemic corticosteroids. Secondary outcomes included unscheduled physician visits, urgent care and emergency department visits, hospital admissions, and exacerbation duration (i.e., time until symptom recovery, lung function recovery, or return to baseline beta₁ agonist use). Nonserious and serious adverse events, including hospitalization, prolongation of hospitalization, disability, fatality, or study withdrawal related to any adverse event, were considered secondary outcomes.^1,5

Among children and adults with mild to moderate persistent asthma, action plans that instructed patients to increase their ICS dose at the onset of worsening asthma symptoms did not reduce asthma exacerbation severity or duration and, therefore, did not reduce the need for systemic corticosteroids. Unscheduled physician visits, visits to the emergency department, and hospitalizations were not reduced. Secondary outcomes, including serious and nonserious adverse events associated with increased ICS dosing, could not be included or excluded due to a lack of clinical significance.¹

These conclusions are limited by biases notable within the individual trials, including differences among studies about the patient's baseline ICS dose, how much the treatment dose of ICS increased, how adherent patients were to their asthma action plan before the trial, and what the patient's baseline asthma severity was.¹ Such biases result in wide CIs that limit the statistical validity and make the quality of data presented less helpful. Of note, study populations were limited to patients with mild to moderate persistent asthma; therefore, conclusions cannot be extended to patients with more severe asthma.

A notable 2018 nonblinded study, which was excluded from this Cochrane review, indicated that quadrupling the ICS dose may reduce systemic corticosteroid use or an unscheduled health care consultation for asthma over 12 months (incidence rate ratio = 0.82; 95% CI, 0.70 to 0.96), particularly among people with more severe asthma.⁶ This review had several challenges, including the absence of a placebo control group, recruitment of a population not taking maintenance ICS, and a design that compared the relative effectiveness of two dosages of ICS as maintenance therapy. Further research is necessary.