Ics asthma
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The Role of Inhaled Corticosteroids (ICS) in Asthma Management
Introduction to Inhaled Corticosteroids (ICS) in Asthma
Inhaled corticosteroids (ICS) are a cornerstone in the treatment of persistent asthma, providing significant benefits in controlling symptoms and reducing exacerbations. Despite their widespread use, the optimal approach to ICS therapy, especially in combination with other medications, remains a topic of ongoing research and debate.
ICS and Asthma Control
Efficacy of ICS in Reducing Exacerbations
ICS are highly effective in reducing asthma exacerbations. Studies have shown that medium-dose ICS combined with long-acting beta2-agonists (LABA) or long-acting muscarinic antagonists (LAMA) significantly reduce moderate to severe asthma exacerbations compared to medium-dose ICS alone1. However, doubling the dose of ICS alone does not provide the same benefit, indicating the importance of combination therapy in managing uncontrolled asthma1.
ICS in Mild Asthma
For patients with mild asthma, ICS are recommended as a maintenance treatment. However, adherence to daily ICS can be challenging, leading many patients to rely on short-acting beta2-agonists (SABA) for symptom relief. Studies suggest that using ICS/formoterol as a reliever is superior to SABA alone and is equivalent to maintenance ICS with SABA as a reliever in reducing severe exacerbations3. This approach can help mitigate the risk of patients reverting to SABA-only treatment, which increases the risk of exacerbations3.
Long-Term Benefits and Risks of ICS
Impact on Lung Function and Mortality
ICS have been shown to improve asthma control, reduce symptoms, and decrease the frequency of exacerbations, which indirectly helps in maintaining lung function over time2. However, the evidence on whether ICS can prevent long-term lung function decline is less clear. While some studies indicate modest improvements in lung function with ICS use, particularly in adults, the impact on preventing fixed airflow obstruction remains uncertain7.
Growth Concerns in Children
One of the concerns with ICS use in children is the potential for growth suppression. Research indicates that higher doses of ICS are associated with a slight reduction in growth velocity compared to lower doses8. This underscores the importance of using the minimal effective dose of ICS in pediatric asthma management to balance efficacy and safety8.
Combination Therapies: ICS with LABA or LAMA
ICS/LABA vs. ICS/LAMA
Adding LABA or LAMA to ICS therapy has been shown to improve asthma control in patients whose symptoms are not well managed with ICS alone. ICS/LABA combinations are particularly effective in reducing moderate to severe exacerbations and improving asthma control questionnaire (ACQ) scores1. On the other hand, ICS/LAMA combinations also reduce exacerbations and may offer additional benefits in lung function, though the evidence is less robust compared to ICS/LABA4 5.
Safety and Adverse Events
The safety profiles of ICS/LABA and ICS/LAMA combinations are generally favorable, with no significant increase in serious adverse events compared to ICS alone1 4. However, the long-term safety of high-dose ICS, particularly in combination therapies, requires further investigation through longer-duration studies1.
Biomarkers and Personalized Treatment
Recent research has explored the use of biomarkers to predict response to ICS and LAMA in patients with mild persistent asthma. Biomarkers such as blood eosinophil levels and fractional exhaled nitric oxide (FeNO) have shown some potential in predicting ICS response, though their predictive power is not yet sufficient for clinical application6. This highlights the need for further studies to refine biomarker-based approaches for personalized asthma management6.
Conclusion
Inhaled corticosteroids remain a fundamental component of asthma management, offering significant benefits in controlling symptoms and reducing exacerbations. Combination therapies with LABA or LAMA enhance these benefits, particularly in patients with uncontrolled asthma. While ICS are generally safe, careful consideration of dose, especially in children, and ongoing research into long-term effects and personalized treatment approaches are essential to optimize asthma care.
Sources and full results
Most relevant research papers on this topic
Addition of long-acting beta2 agonists or long-acting muscarinic antagonists versus doubling the dose of inhaled corticosteroids (ICS) in adolescents and adults with uncontrolled asthma with medium dose ICS: a systematic review and network meta-analysis.
Adding a LABA or LAMA to inhaled corticosteroids may reduce moderate to severe asthma exacerbations compared to doubling the dose of ICS in adolescents and adults with uncontrolled asthma.
Meta-AnalysisAsthma progression and mortality: the role of inhaled corticosteroids
Inhaled corticosteroids (ICS) improve asthma control and may prevent lung function decline by preventing severe exacerbations, but their long-term impact on asthma progression and mortality remains unclear.
Literature Review
Rigorous Journal
Highly CitedThe management of mild asthma
An ICS-containing reliever medication is superior to SABA as reliever alone and is equivalent to maintenance ICS and SABA as reliever, particularly in reducing severe asthma exacerbations.
Systematic ReviewRigorous JournalLong-acting muscarinic antagonists (LAMA) added to inhaled corticosteroids (ICS) versus the same dose of ICS alone for adults with asthma.
LAMA add-ons to inhaled corticosteroids can reduce the need for oral corticosteroids in adults with asthma, improving quality of life and reducing exacerbations.
Meta-Analysis
Very Rigorous JournalLong-acting muscarinic antagonists (LAMA) added to combination long-acting beta2-agonists and inhaled corticosteroids (LABA/ICS) versus LABA/ICS for adults with asthma.
Adding long-acting muscarinic antagonists to combination LABA/ICS may reduce the need for oral corticosteroids in adults with asthma not well controlled by LABA/ICS alone.
Meta-AnalysisVery Rigorous JournalHighly CitedBiomarkers to Predict Response to ICS and LAMA in Adolescents and Adults with Mild Persistent Asthma.
Biomarkers predicting response to inhaled corticosteroids and long-acting muscarinic antagonists may differ in adults and adolescents with mild persistent asthma.
RCTDoes the use of inhaled corticosteroids in asthma benefit lung function in the long-term? A systematic review and meta-analysis
Inhaled corticosteroids are associated with modest, age-dependent improvements in long-term lung function in patients with mild asthma, but their impact on fixed airflow obstruction remains unclear.
Meta-AnalysisInhaled corticosteroids in children with persistent asthma: dose-response effects on growth.
Increasing the dose of inhaled corticosteroids in children with persistent asthma may lead to slower linear growth, weight gain, and skeletal maturation.
Meta-AnalysisVery Rigorous JournalLong-acting muscarinic antagonists (LAMA) added to inhaled corticosteroids (ICS) versus addition of long-acting beta2-agonists (LABA) for adults with asthma.
Adding a LAMA to inhaled corticosteroids may not be as effective as adding a LABA for adults with asthma not well controlled on ICS alone, with low confidence in the effect due to inconsistency between studies.
Meta-AnalysisVery Rigorous JournalA review of the burden and management of mild asthma in adults - Implications for clinical practice.
'Mild' asthma is often not well controlled and can significantly impact patients' symptom burden and quality of life, with under-prescription of inhaled corticosteroids and miscommunication between patients and physicians affecting diagnosis and management.
Systematic ReviewRigorous Journal