Inhaled Corticosteroids as Rescue Medication in Acute Severe Asthma

Gustavo J Rodrigo

Disclosures

Expert Rev Clin Immunol. 2008;4(6):723-729. 

In This Article

Expert Commentary & Five-year View

The characteristics of nongenomic effects of CS are:

  • Acute

  • Transitory

  • Dose dependent

  • Correlate (directly) with baseline airway blood flow

  • More powerful with budesonide or fluticasone than with beclometasone

  • Can improve β2-adrenergic bronchodilation

These vascular effects of inhaled CS on the airways could be expected to have therapeutic implications for the management of acute asthma and its characteristics are fundamental to establish the optimum dose and timing of administration in the ED setting. Inhaled CS should, essentially, be administered frequently and in high doses in order to maintain their effects, most particularly in patients with severe obstruction. Since inhaled CS induce vasoconstriction peaks between 30 and 60 min following drug administration, their use in intervals of at least 30 min seems adequate.

There is clinical evidence that supports the use of inhaled CS for the treatment of children and adults with asthma exacerbations as rescue medication in the ED. Even though systemic CS remain the treatment of choice for acute asthma, this early and probably nongenomic effect may be significant in the treatment of the most severe cases. Thus, on the basis of this evidence, the use of inhaled fluticasone or budesonide through a MDI and spacer or nebulization every 10-30 min could be recommended ( Box 1 ). Although there was important variation between studies, the evidence suggests that the minimum effective nebulized doses for fluticasone and budesonide would be 500 µg every 15 min, and 800 µg every 30 min, respectively. The use of 400 µg every 30 min of budesonide via a MDI and spacer was also effective, and greater doses (fluticasone 500 µg every 10 min by a MDI) generated larger benefits. These doses would have to be administered over a minimum of 90 min, although more prolonged periods of administration could generate a greater benefit. Nevertheless, future studies would have to clarify the relationship between the dose administered, acute asthma severity and response to treatment.

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