Corticosteroid Therapy

Introduction to Corticosteroids

The American Academy of Allergy, Asthma, and Immunology recommends that inhaled corticosteroids (ICS) are the most consistently effective long-term control medications for persistent asthma in all steps of care 1
ICS improve asthma control more effectively than leukotriene receptor antagonists (LTRA) or any other single long-term control medication 1
ICS reduce deterioration and the risk of exacerbations, but do not appear to alter the underlying progression or severity of the disease in children 1

The recommended dosages for persistent mild asthma are: beclomethasone dipropionate 200-500 μg/day, budesonide 200-400 μg/day, and fluticasone propionate 100-250 μg/day 2
For acute exacerbations of asthma, oral dexamethasone 16 mg daily for 2 days or prednisolone 30-60 mg daily for 5-10 days are equivalent options 3

ICS reduce airway hyperreactivity, inhibit the migration and activation of inflammatory cells, and block the late-phase reaction to allergens 1
ICS reduce the need for short-acting bronchodilator supplements, oral corticosteroid courses, and hospitalizations 2
For moderate persistent asthma, adding a long-acting beta-agonist (LABA) to low-dose ICS is preferred over increasing the ICS dose alone 2
LABAs should never be used as monotherapy for asthma, as this increases the risk of severe exacerbations and asthma-related deaths 2

The European League Against Rheumatism (EULAR) guidelines recommend using the lowest dose for the shortest possible duration to minimize cardiovascular risk 5
Current users of oral corticosteroids have an odds ratio (OR) of 2.7 for developing atrial fibrillation compared to non-users 5
High-dose corticosteroids (≥7.5 mg prednisone equivalent) carry an OR of 6.07 for atrial fibrillation 5

Common local effects of ICS include oral candidiasis, hoarseness, and dysphonia 2
Using a spacer or valved holding chamber with metered-dose inhalers reduces oropharyngeal deposition and minimizes local side effects 2
Instructing patients to rinse their mouth and spit after each inhalation further reduces local adverse effects 2

The preferred approach to stepping up treatment is to add a LABA to low-dose ICS instead of increasing the ICS dose alone 2
Once asthma control is maintained for 2-4 months, therapy should be reduced to the minimum dose required to maintain control 2
Continue monitoring for at least 3 months of stable control before considering further dose reduction 2