As-needed inhaled corticosteroids in asthma: from evidence to implementation

Purpose of review This review aims to clarify the role of as-needed ICS through the severity spectrum of adult asthma and explores the challenges associated with implementation. This review is timely following the recent US Food and Drug Administration (FDA) approval of an ICS/SABA combination inhaler. Recent findings In 2019, the Global Initiative for Asthma (GINA) recommended against the use of short-acting beta agonist (SABA) monotherapy and officially endorsed the use of as-needed inhaled corticosteroid with a fast-acting bronchodilator [anti-inflammatory reliever (AIR)] as the preferred strategy across all treatment steps. In 2020, the US NHLBI asthma guidelines recommended ICS+SABA at step 2, and ICS/formoterol to be used as maintenance and reliever therapy (MART) at treatment steps 3 and 4. Despite these strong recommendations, uptake of this strategy in the United States has been slow. Barriers to MART implementation are explained, and implementation strategies are reviewed. Summary Transition to a single ICS/formoterol inhaler as MART from traditional multiinhaler regimens offers the opportunity for multidomain benefits. The role of novel ICS/SABA combination inhalers remains to be determined across the continuum of asthma.