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Evidence summaries

Initial Starting Dose of Inhaled Corticosteroids for Asthma

In the treatment of asthma, commencing with a moderate dose of inhaled corticosteroids (ICS) appears to provide equivalent clinical benefits as commencing with a high dose ICS and down-titrating. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 26 trials. In comparisons of a step down approach to a constant moderate/low inhaled corticosteroid (ICS) dose (7 studies, n=1 396), there were no significant differences in lung function, symptoms, rescue medications or asthma control between the two treatment approaches. Significant but clinically small improvements in percent predicted FEV1 ( WMD 5.32, 95% CI 0.65 to 9.99) and non significant improvements in the change in morning PEF were found for high dose ICS compared to moderate dose ICS (11 studies, n=1 749). There were no significant differences in efficacy between high and low dose ICS (9 studies, n=1 136). For moderate dose ICS compared to low dose ICS (11 studies, n=1 971), there were significant improvements in the change in morning PEF l/min from baseline (WMD 11.14, 95% CI 1.34 to 20.93) and nocturnal symptoms (SMD -0.29, 95% CI -0.53 to -0.06 ). Commencing ICS at double or quadruple a base moderate or low dose had no greater effect than commencing with the base dose. Several studies reported greater improvement in airway hyperresponsiveness for high dose ICS.

Another Cochrane review[Abstract]1included 6 trials involving a total of 1654 adults (ICS and concomitant long-acting beta agonist (LABA) 3 trials and ICS and no LABA 3 trials). There was no statistically significant or clinically relevant differences between groups with respect to any of the outcomes (exacerbation requiring oral corticosteroids or hospitalisation, asthma control, all-cause or steroid related adverse effects, health-related quality of life, or lung function). However, the data were insufficient to rule out benefit or harm because of low number of studies with varied outcomes and wide confidence intervals.

For the classification of ICS dosage (British Thoracic Society guidelines), see Table T1

The following decision support rules contain links to this evidence summary:

Classification of ICS dosage (British Thoracic Society guidelines)

DoseFluticasone propionateBudesonide or beclomethasone
High dose - Adults≥400 mcg/day≥800 mcg/day
High dose - Children≥200 mcg/day≥400 mcg/day
Moderate dose - Adults≥200 but < 400 mcg/day≥400 but < 800 mcg/day
Moderate dose - Children≥100 but < 200 mcg/day≥200 but < 400 mcg/day
Low dose - Adults<200 mcg/day<400 mcg/day
Low dose - Children<100 mcg/day<200 mcg/day

    References

    • Powell H, Gibson PG. High dose versus low dose inhaled corticosteroid as initial starting dose for asthma in adults and children. Cochrane Database Syst Rev. 2003;(4):CD004109 [Abstract and commentary in Evidence-Based Medicine 2004 Nov-Dec;9(6):178].
    • Crossingham I, Evans DJ, Halcovitch NR et al. Stepping down the dose of inhaled corticosteroids for adults with asthma. Cochrane Database Syst Rev 2017;(2):CD011802. [PubMed]

Primary/Secondary Keywords