Continuous Corticosteroids Best for Mild, Well-Controlled, Asthma? - Medscape

Inhaled corticosteroids (ICSs) are recommended as a first-line treatment for asthma, but many clinicians are challenged to determine whether patients with mild, well-controlled asthma should continue or discontinue their ICS treatment.

Previous research suggests that for patients with mild asthma, the asthma can continue to be well controlled after discontinuance of frontline therapy. However, a new long-term study suggests that maintaining ICS treatment may lead to better control and more favorable outcomes for some patients with mild, persistent, well-controlled disease.

Compliance to asthma therapy can be difficult for many patients, and lack of adherence often leads to asthma exacerbations. Although ICS therapy is generally recommended, there is a potential long-term risk for certain side effects.

Given this risk for possible adverse effects, clinicians are sometimes called to determine whether ICS can be discontinued or substantially reduced for patients whose disease is well controlled.

In the DISCO (Discontinuation of Inhaled Steroid in Controlled Asthmatics Over 6 Months) study, researchers examined the clinical outcomes of patients with well-controlled, mild asthma for whom ICS was discontinued. The investigators compared the outcomes of those patients with outcomes for patients who continued receiving ICS therapy for approximately 3 years. Findings from the study were published online July 1 in the Annals of Allergy, Asthma and Immunology.

The researchers observed a significant difference in the time to loss of disease control between those for whom ICS was stopped in comparison with those whose therapy was continued (hazard ratio, 2.56; 95% CI, 1.52 – 4.33; P < .001).

There was a significant yet weak association between the risk of losing disease control and rising levels of fractional exhaled nitric oxide (P = .008) and sputum eosinophil counts (P = .015) in the continuous ICS group.

Significantly higher sputum eosinophil counts (P = .039) and levels of serum total immunoglobulin E (P = .014) were observed in the loss-of-control group compared with the group that continued therapy and achieved stable disease control.

Dr Asriani Chiu

"Patients do not always do what we recommend nor use medicines consistently once they feel they are doing better or are doing well," said Asriani Chiu, MD, an allergy and immunology specialist at the Medical College of Wisconsin, Wauwatosa, Wisconsin. "Many patients will stop medicines once they feel their symptoms are controlled."

Chiu, who wasn't involved in the DISCO study, explained to Medscape Medical News that the benefits of continuing ICS include improvements or maintained improvements in asthma control and decreased inflammation in the lungs.

"The drawbacks [of ICS use] include costs of the medication as well as possible systemic absorption/side effects," she added. "Even though systemic absorption of steroids from ICS is far less than oral steroids, there still can be side effects with any medication, so trying to use the least amount of medication that is needed to control symptoms is important."

Dr James Li

"For patients with asthma who are treated with ICS, some may deteriorate after ICS therapy is stopped, while others may not," said James Li, MD, an allergist and immunologist at the Mayo Clinic, Rochester, Minnesota.

But deciding whether to discontinue ICS can be tricky, added Li. "Continuing is an option — as the saying goes, 'If it ain't broke, don't fix it,' " he said. "Stopping ICS also makes sense for certain patients, because who wants to take medicine they don't need?"

Li emphasized that clinicians should ensure that patients who do discontinue ICS receive appropriate education on identification and prompt management of symptoms should they occur. Clinicians should also carefully and routinely monitor asthma following ICS withdrawal.

Chiu added that whether to continue or stop ICS should be based on shared decision making between patients, families, and the practicing clinician.

The study authors and Chiu have disclsoed no relevant financial relationships. Li has received consulting fees from GlaxoSmithKline.

Ann Allergy Asthma Immunol. Published online July 1, 2021. Abstract

Brandon May is a freelance medical journalist who has written more than 900 articles for medical publications in the United States and the United Kingdom. He resides in downtown Brooklyn, New York City. Twitter: @brandonmilesmay.

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