Early interventions with inhaled corticosteroids in asthma: benefits and risks

PURPOSE OF REVIEW: the present review examines the effects of early intervention with inhaled corticosteroids (ICSs) on clinical efficacy and natural history of asthma based on two recent clinical trials: the Inhaled Steroid Treatment as Regular Therapy in Early Asthma (START) and Prevention of Early Asthma in Kids (PEAK) trials, and a comparison of the effect of regular vs. intermittent therapy based on the Improving Asthma Control Trial (IMPACT). RECENT FINDINGS: in most patients, both adults and children, who have a new diagnosis of asthma and whose symptoms are mild but persistent, treatment with ICS should be recommended as soon as the diagnosis is made. This is a cost-effective and well tolerated treatment. However, symptoms may recur and lung function may decline again if treatment is discontinued. SUMMARY: ICS is the most cost-effective initial treatment for both adults and children with a new diagnosis of asthma. If patients are reluctant to use ICS daily for long periods, it would be reasonable to delay the onset of treatment with ICS. Initial therapy with leukotriene receptor antagonist is not likely to be as effective as initial therapy with ICS. Biomarkers of airway inflammation such as sputum cell counts and exhaled nitric oxide are probably not necessary to treat patients with mild intermittent asthma.