The quality of evidence is downgraded by study limitations (lack of/unclear allocation concealment and imprecise results).
A Cochrane review [Abstract] 1 included 6 trials with a total of 1 211 participants comparing daily inhaled corticosteroids (ICS) to intermittent, as needed, ICS. The treatment group received patient-initiated intermittent ICS at the onset of exacerbations and continued for a short duration. The control group received daily ICS between and during exacerbations. Rescue β2-agonists and oral corticosteroids were permitted as co-interventions. The age of the participants was 1-5 years in 2 studies (n=498), 5 to 18 in 3 studies (n=401), and over 18 years in 2 studies (n=383). The duration of follow-up varied from 3 to 12 months.
No statistically significant difference was observed between the groups in the risk of exacerbations of asthma requiring oral corticosteroids (table T1), hospitalisations, emergency department visits, withdrawals, or quality of life. However, daily ICS was superior to intermittent ICS in indicator of lung function (PEFR) and asthma control. This result was not affected by patients' age, severity of airway obstruction, step-up protocol used during exacerbations and trial duration. In paediatric trials, a modest growth suppression of 0.41 cm was associated with daily ICS with budesonide and beclomethasone, compared to intermittent ICS.
| Intermittent 'as needed' ICS versus daily ICS for persistent asthma in children and adults | ||||
|---|---|---|---|---|
| Outcome | Number of participants (studies) | Assumed risk - Control (daily ICS) | Corresponding risk - Intervention (intermittent ICS, 95% CI) | Effect size (95 % CI) |
| Exacerbations requiring oral corticosteroids | 1204(7) | 19 per 100 | 20 (17 to 25) per 100 | RR 1.07(0.87 to 1.32) |
| Exacerbations requiring acute care visit | 1055(6) | 15 per 100 | 18 (14 to 20) per 100 | RR 1.1(0.9 to 1.3) |
| Change from baseline mean daily use of β2-agonists (puffs/day) | 442(3) | The mean change from baseline mean daily use of β2-agonists in the intermittent ICS groups was 0.12 puffs/day higher than daily ICS group (0 to 0.23 higher) | MD 0.12(0.00 to 0.23) | |
| Change in height (cm) | 532(4) | The mean change in height (cm) in the intermittent groups was 0.41 cm higher than daily ICS group (0.13 to 0.69 higher) | MD 0.41(0.13 to 0.69) | |
There is insufficient evidence on the use of intermittent corticosteroids in patients with severe or frequent exacerbations of asthma and on their long-term effectiveness. If better symptom control is needed, continuous inhaled corticosteroids should be preferred.
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