Am Fam Physician. 2016;94(1):21-22
Author disclosure: No relevant financial affiliations.
Clinical Question
Is the use of intermittent inhaled corticosteroid therapy safe and effective for mild persistent asthma in children and adults?
Evidence-Based Answer
Intermittent inhaled corticosteroid therapy reduces the risk of asthma exacerbations in children and adults with mild persistent asthma. Intermittent use appears to be safe in these patients. (Strength of Recommendation: B, based on limited-quality evidence from randomized controlled trials.)
Practice Pointers
Asthma accounts for 14.2 million office visits to U.S. physicians (1.4% of all encounters) each year and is responsible for significant respiratory-associated morbidity and mortality.1 Symptoms such as wheezing, cough, and dyspnea can vary in timing and intensity. Clinical management includes quantifying asthma severity and providing patient education, environmental control, and stepwise treatment with medications, if required.2 Daily inhaled corticosteroid therapy for children and adults is recognized as standard treatment for persistent asthma.2 However, for patients with mild persistent asthma symptoms, optimal inhaled corticosteroid use has not been determined. This Cochrane review studied whether intermittent inhaled corticosteroids initiated at the time of an exacerbation could safely manage mild persistent asthma in children and adults without the need for oral corticosteroids.
The Cochrane review included six double-blind, placebo-controlled, randomized trials enrolling 490 preschool-aged children up to five years of age, 145 school-aged children, and 240 adults. In all trials, intermittent inhaled corticosteroid therapy was compared with placebo, and rescue inhalers and oral corticosteroids were the only cointerventions allowed during exacerbations. The protocols for how to use intermittent inhaled corticosteroid therapy varied, but usually involved taking inhaled corticosteroids with a bronchodilator as needed to relieve symptoms. Preschool-aged children with suspected asthma symptoms were analyzed separately from adults and children with confirmed asthma. Primary outcomes included asthma exacerbations requiring oral corticosteroids and serious adverse effects.
In an analysis of two randomized controlled trials, the risk of asthma exacerbation requiring use of oral corticosteroids was lower among school-aged children (odds ratio [OR] = 0.57; 95% confidence interval [CI], 0.29 to 1.12) and adults (OR = 0.10; 95% CI, 0.01 to 1.95) with mild persistent asthma symptoms who were randomized to intermittent inhaled corticosteroid therapy vs. placebo. When the data from these two trials were combined, the odds of experiencing an asthma exacerbation requiring use of oral corticosteroids for persons using intermittent inhaled corticosteroid therapy was one-half that of those given placebo (OR = 0.50; 95% CI, 0.26 to 0.94). The corresponding number needed to treat was 11 (95% CI, 7 to 100). A separate analysis that included four randomized trials of intermittent inhaled corticosteroid therapy in preschool-aged children with wheezing found results consistent with those seen in adults and school-aged children (OR = 0.48; 95% CI, 0.31 to 0.73), with a number needed to treat of 7 (95% CI, 5 to 14). No difference in the odds of serious adverse effects in children and adults was noted (OR = 1.00; 95% CI, 0.14 to 7.25).
The 2007 National Asthma Education and Prevention Program's stepwise approach for managing asthma does not include guidelines for use of intermittent inhaled corticosteroid therapy.2 This is the second Cochrane review published since 2007 to demonstrate that intermittent inhaled corticosteroid therapy is safe and effective for children and adults with mild persistent asthma.3 However, the small number of studies limits confidence in the evidence. Further randomized trials in clinical practice settings are needed before guidelines can routinely recommend intermittent inhaled corticosteroid therapy for mild persistent asthma.
The practice recommendations in this activity are available at http://summaries.cochrane.org/CD011032.
SOURCE: ChongJHaranCChauhanBFAsherIIntermittent inhaled corticosteroid therapy versus placebo for persistent asthma in children and adults. Cochrane Database Syst Rev2015;(7):CD011032.
