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Mild asthma: adapt treatment according to patients’ needs

An inhaled beta-2 agonist as needed, possibly combined  with an as-needed or continuous inhaled corticosteroid.

Asthma is a chronic inflammation of the airways that manifests itself by the occurrence of exacerbations, known as asthma attacks. Asthma is considered to be mild when the symptoms do not occur every day and are not persistent. They generally abate spontaneously; or after inhalation of a short-acting beta-2 agonist (salbutamol or terbutaline). The daily addition of an inhaled corticosteroid (beclometasone or budesonide) helps to prevent asthma attacks.

In 2019 however, the international group Global Initiative for Asthma issued a recommendation that asthma patients take an on-demand, low-dose inhaled corticosteroid, in combination with formoterol (a long-acting beta-2 agonist with a rapid onset of action) as long as asthma attacks do not occur more than once a month. When symptoms occur more than once a month but not every day, this combination is also proposed as an alternative to daily treatment with a low-dose inhaled corticosteroid and a short-acting beta-2 stimulant during attacks. These recommendations are based on the results of a trial including patients whose asthma was particularly troublesome and who were treated with the budesonide + formoterol combination marketed by the firm that funded the trial.

As of early 2020, according to Prescrire’s systematic review, as-needed treatment with salbutamol or terbutaline remains the first-choice treatment for the large number of patients whose asthma is not very bothersome. When asthma symptoms are still too bothersome, inhaled corticosteroid therapy is justified. Two options can then be considered: either daily inhaled corticosteroid therapy and treatment of exacerbations with salbutamol or terbutaline, or, alternatively, as-needed treatment of exacerbations with an inhaled corticosteroid combined with a beta-2 agonist that has a rapid onset of action (salbutamol, terbutaline or formoterol). The budesonide + formoterol combination is one of a number of options.

©Prescrire 1 September 2020

Source: "Treatment of mild asthma. An inhaled beta-2 agonist during exacerbations, possibly combined with an as-needed inhaled corticosteroid" Prescrire International 2020; 29 (218): 217. Subscribers only.

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For more information:

"Asthma. A summary of
first-choice treatments"
Prescrire Int 2016;
25 (169): 73-76.
Pdf, free


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