As-needed inhaled corticosteroids in asthma: an Official American Thoracic Society clinical practice guideline

BACKGROUND: Inhaled corticosteroid (ICS)-containing reliever therapy has demonstrated efficacy in improving asthma outcomes when compared to short-acting beta2-agonists (SABA) alone but remains underutilized. The purpose of this guideline is to provide recommendations surrounding the use of combination ICS-formoterol or ICS+SABA (in combination or separate inhalers) as reliever therapy across the asthma severity spectrum in adolescents and adults. METHODS: The American Thoracic Society clinical practice guideline panel evaluated six research questions in the PICO format addressing the use of ICS-containing reliever therapy across National Asthma Education and Prevention Program (NAEPP) asthma treatment steps 1-5. The methodology team conducted systematic literature reviews and GRADE assessments, which the panel utilized to inform the recommendations for each specific PICO and overall. RECOMMENDATIONS: In patients at NAEPP steps 1 and 2, the panel made strong recommendations for the use of as-needed-only ICS-SABA or ICS-formoterol over SABA-only therapy, and conditional recommendations over scheduled ICS + as-needed SABA. In patients at NAEPP steps 3-5, the taskforce made a strong recommendation for the use of maintenance-and-reliever therapy (MART) with ICS-formoterol over scheduled ICS-LABA plus as-needed SABA. In patients at NAEPP steps 3-5 who are using scheduled maintenance ICS-LABA, the panel made a conditional recommendation for use of ICS+SABA reliever over SABA reliever. In considering these recommendations, the panel valued the importance of preventing severe exacerbations and considered the risk of SABA-only treatment, as well as ICS and systemic corticosteroid (SCS) exposure. CONCLUSIONS: This clinical practice guideline, informed by systematic reviews and GRADE-based appraisals of PICO-framed evidence, makes these evidence-based recommendations for the safe and effective use of ICS-containing reliever therapy in asthma.