Does Increasing Inhaled Corticosteroid Dose for Asthma Attacks Reduce Need for Rescue Medication?

Increasing inhaled corticosteroids during exacerbations of chronic asthma does not appear to reduce the need for rescue oral steroids, suggests an updated review in the Cochrane Database of Systematic Reviews.

“People with asthma may experience exacerbations, or ‘attacks,’ during which their symptoms worsen and additional treatment is required,” the authors explained. “Written action plans sometimes advocate a short‐term increase in the dose of inhaled corticosteroids at the first sign of an exacerbation to reduce the severity of the attack and to prevent the need for oral steroids or hospital admission.”

The updated review included nine randomized controlled trials, conducted in Europe, North America, and Australasia and published between 1998 and 2018. Among the total 1923 participants in the trials, 1247 were adults and 676 were children or adolescents with mild to moderate asthma.

Participants who increased their inhaled corticosteroid dose at the first sign of an exacerbation demonstrated similar odds of needing rescue oral corticosteroids as participants who maintained a stable daily dose, according to the review. Researchers were unable to draw firm conclusions on how factors such as age, time to treatment initiation, baseline dose, smoking history, and fold increase of inhaled corticosteroids affected the need for rescue oral corticosteroids.

“Pooled effects for unscheduled physician visits, unscheduled acute care, emergency department or hospital visits, and duration of exacerbation made it very difficult to determine where the true effect may lie,” researchers wrote, “and confidence was reduced by risk of bias.”

Analysis of serious and nonserious adverse events favored maintaining a stable dose of inhaled corticosteroids rather than increasing the dose. However, researchers again acknowledged reduced confidence in the finding, citing “imprecision and risk of bias due to missing data and outcome measurement and reporting” in the studies.

“Other clinically important benefits and potential harms of increased doses of inhaled corticosteroids compared with keeping the dose stable cannot be ruled out due to wide confidence intervals, risk of bias in the trials, and assumptions that had to be made for synthesis,” the authors advised.

They recommended a systematic review examine the differences between the trials using robust methods to determine risk of bias to provide a more complete view of evidence.

Reference:
Kew KM, Flemyng E, Quon BS, Leung C. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children. Cochrane Database Syst Rev. 2022;9(9):CD007524. doi:10.1002/14651858.CD007524.pub5