As-needed inhaled corticosteroids in asthma: an...

As-needed inhaled corticosteroids in asthma: an Official American Thoracic Society clinical practice guideline

Abstract

Abstract Background Inhaled corticosteroid (ICS)-containing reliever therapy has demonstrated efficacy in improving asthma outcomes when compared to short-acting beta2-agonists (SABA) alone but remains underutilized. The purpose of this guideline is to provide recommendations surrounding the use of combination ICS-formoterol or ICS+SABA (in combination or separate inhalers) as reliever therapy across the asthma severity spectrum in adolescents and adults. Methods The American Thoracic Society clinical practice guideline panel evaluated six research questions in the PICO format addressing the use of ICS-containing reliever therapy across National Asthma Education and Prevention Program (NAEPP) asthma treatment steps 1-5. The methodology team conducted systematic literature reviews and GRADE assessments, which the panel utilized to inform the recommendations for each specific PICO and overall. Recommendations In patients at NAEPP steps 1 and 2, the panel made strong recommendations for the use of as-needed-only ICS-SABA or ICS-formoterol over SABA-only therapy, and conditional recommendations over scheduled ICS + as-needed SABA. In patients at NAEPP steps 3-5, the taskforce made a strong recommendation for the use of maintenance-and-reliever therapy (MART) with ICS-formoterol over scheduled ICS-LABA plus as-needed SABA. In patients at NAEPP steps 3-5 who are using scheduled maintenance ICS-LABA, the panel made a conditional recommendation for use of ICS+SABA reliever over SABA reliever. In considering these recommendations, the panel valued the importance of preventing severe exacerbations and considered the risk of SABA-only treatment, as well as ICS and systemic corticosteroid (SCS) exposure. Conclusions This clinical practice guideline, informed by systematic reviews and GRADE-based appraisals of PICO-framed evidence, makes these evidence-based recommendations for the safe and effective use of ICS-containing reliever therapy in asthma.