Evaluating as-needed inhaled corticosteroid strategies in asthma: expanding the benefits to mild asthma

ABSTRACT

Introduction

Adherence to regular anti-inflammatory treatment is commonly low, and short-acting β2 agonist (SABA) overuse is common in patients with asthma, leading to an increased risk of asthma-related adverse events.

Areas covered

Given the pivotal role of inflammation in asthma, multiple as-needed inhaled corticosteroid (ICS)-containing therapies have been developed, leading to a reduction in asthma exacerbations and improvement in symptom control. Currently, as-needed ICS/formoterol is one of the most commonly available formulations; however, other combinations such as ICS/SABA have been shown to be superior to as-needed SABA alone. Therefore, we performed a comprehensive review of the available scientific literature to enhance the advantages and disadvantages of each combination in clinical practice.

Expert opinion

The future direction we foresee in asthma management consists in abandoning as-needed short-acting bronchodilators in favor of as-needed ICS-containing therapies. Each patient is unique and differs from others; consequently, a single option will not fit everyone. Patients’ and physicians’ awareness of this perspective can be reached through the development of multiple therapeutic options suitable for each condition that can be found in ‘real life’.

KEYWORDS:

• Asthma
• as-needed
• ICS
• inflammation
• mild
• SABA
• treatment

Article highlights

• As short-acting β2 agonists (SABA) do not control airway inflammation, they are ineffective in preventing asthma exacerbation.

• Overuse of SABAs is common, leading to an increased risk of asthma exacerbation and death.

• Adherence to maintenance therapy is low across the spectrum of asthma severity, especially mild asthma, in relation to the underestimated risk of asthma exacerbations.

• Inhaled corticosteroid (ICS)/formoterol combination therapy as a rescue medication reduces exacerbation risks compared with SABA rescue therapy.

• ICS/SABA combination therapy as a rescue is more effective than rescue SABAs in reducing exacerbation risk and improving symptom control.

• At any step of asthma treatment, rescue medications containing ICSs are available and are more effective than rescue SABAs.

Declaration of interest

A Papi received grants for research from Chiesi, AstraZeneca, GSK, BI, Pfizer, Teva, Sanofi; consulting fees from Chiesi, AstraZeneca, GSK, Mundipharma, Novartis, Boehringer Ingelheim, Edmond, Sanofi, Avillion, IQVIA, Elpen Pharmaceuticals, TEVA, MSD, lecture fees form Chiesi, AstraZeneca, GSK, Mundipharma, Sanofi, MSD, Novartis, Zambon.

M Contoli reports personal fees from Alk-Abello; grants, personal fees and non-financial support from Chiesi, personal fees and non-financial support from AstraZeneca, personal fees and non-financial support from Boehringer Ingelheim, grants, personal fees and non-financial support from GlaxoSmithKline, personal fees and nonfinancial support from Novartis, personal fees and non-financial support from Zambon, grants from University of Ferrara – Italy, outside the submitted work. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has performed consulting, served on advisory boards, or received travel reimbursement from Amphastar, AstraZeneca, Chiesi, Connect Biopharma, GlaxoSmithKline, Mylan, Novartis, Sunovion and Theravance. They have also conducted multicenter clinical research trials for some 40 pharmaceutical companies. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Acknowledgments

The authors thank E. Veratelli for her support in editing and submitting the manuscript.

Additional information

Funding

This paper was not funded.