First-Line Treatment for Adults with Reactive Airway Disease Using Inhaled Corticosteroids (ICS)

Treatment Algorithm

Inhaled corticosteroids (ICS) should be considered as first-line treatment for adults with Reactive Airway Disease, according to the American College of Chest Physicians 1, 2
The American College of Chest Physicians recommends starting with low to medium doses of ICS, as higher starting doses have not demonstrated additional clinical benefits in most efficacy parameters 1, 2
ICS are effective on a twice daily dosing schedule, with proper inhaler technique and use of appropriate delivery devices, such as large volume spacers with metered-dose inhalers (MDIs) to improve drug delivery 3
If symptoms are not controlled on standard doses, consider increasing to higher doses of inhaled steroids up to a daily equivalent of 2000 μg beclomethasone, as recommended by the British Medical Journal 3

The American Academy of Allergy, Asthma, and Immunology recommends adding a long-acting beta2-agonist (LABA) to low-medium dose ICS rather than further increasing the ICS dose, with strong evidence consistently indicating improved outcomes 4, 5
This combination approach may allow for control of asthma and airway inflammation at lower ICS doses, according to the Journal of Allergy and Clinical Immunology 4, 5

Allow a one to three month period of stability before attempting stepwise reduction in inhaled steroids, with a decrease of 25-50% at each step, as recommended by the British Medical Journal 3
Monitor for symptom control, with patients requiring short-acting beta2-agonists more than two or three times daily maintained on or started on ICS, according to the British Medical Journal 3

The British Journal of Pharmacology recommends considering dry powder inhalers (DPIs) as first-line options for many patients, as they may be preferred over MDIs and have lower environmental impact 9
Non-invasive measurement of airway inflammation, such as fractional exhaled nitric oxide, may have clinical utility in predicting response to corticosteroids, according to the American College of Chest Physicians 1, 2
Be aware of potential adverse effects with high-dose ICS, including adrenal suppression, local side effects, and increased risk of pneumonia, as reported by the Thorax journal 10

For patients with refractory symptoms, consider checking for proper inhaler technique, medication adherence, and alternative diagnoses before escalating therapy, as recommended by the British Medical Journal 3
In cases of acute exacerbations, oral corticosteroids should be used, with no advantage to intravenous administration, according to the British Medical Journal 3
For patients with non-asthmatic eosinophilic bronchitis (NAEB), ICS are also the first-choice treatment, as recommended by the American College of Chest Physicians 2, 8