Clinical usage

Inhaled steroids should be introduced to an asthmatic patient with any of the following features:

• exacerbations of asthma in the last two years
• using inhaled β2 agonists three times a week or more
• symptomatic three times a week or more
• nocturnal symptoms disrupt sleep on one or more nights a week for more than a month (1).

For atopic children with asthma, sodium cromoglycate should be used before glucocorticoids in order to minimise the risk of growth suppression.

For mild symptoms, 200 micrograms bd of inhaled steroids is a starting dose. The therapeutic effect is not complete until 2 months' treatment and so full reassessment should be withheld until this time. If control is still poor after this time, increments to 400, 800 then 1000 micrograms bd should be considered (note that side effects are much more likely to occur with higher doses of inhaled steroids (>800micrograms per day of beclomethasone or equivalent, in adults)).

Severe symptoms need first-line systemic steroids and bronchodilators. The rate of improvement of peak flow and symptoms determines the steroid requirement and route:

• rapid improvement: stop orals and start inhaled glucocorticoids immediately, 200-400 micrograms bd
• slow improvement: keep on high dose prednisolone and introduce inhaled steroids to maximum dose - 1.6mg-2.0mg per day. Reduce oral requirements at a rate of 5-10mg per week.
• slow improvement despite maximal inhaled and oral therapy: reduce oral dose slowly by 1mg/day over a long period

The dose of inhaled glucocorticoids should be reviewed regularly with a view to reduction. A reasonable stepwise decrease is 200 micrograms every 3 months, particularly in mild to moderate severity disease. If reduction is accompanied by re-emergence of poor control, the original dose should be restarted and not reduced again for at least a year.

Reference:

• (1) Scottish Intercollegiate Guidelines Network (SIGN) and British Thoracic Society (BTS) 2009. British guideline on the management of asthma: a national clinical guideline (revised 2009).