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Low-dose inhaled corticosteroids (ICS) substantially lower the risk for asthma exacerbations and mortality and are therefore essential for every patient with asthma. In everyday practice, a central question is what to do when that low dose no longer provides adequate control — the 21st Francophone Congress of Allergology laid out the recommended approach.

“ICS treatment is indispensable and must be given to every person with asthma, whatever the delivery strategy — no patient should rely only on rescue medication without ICS,” insists Cécile Chenivesse, professor and head of the Department of Pulmonology and Immuno-Allergology at Lille University Hospital, Lille, France.

This also applies to mild asthma. A post hoc analysis of the START study in patients aged 4-66 years with fewer than one symptom per week showed that low-dose inhaled budesonide at 400 mg/d compared with placebo lowered the risk for serious respiratory events, including hospitalization or death, by 34% and reduced the need for oral corticosteroid therapy by 52%.

They also alleviate symptoms, reducing the number of symptomatic days, the proportion of patients with limitations in physical activity, and the proportion experiencing sleep disturbances.

A 2021 study showed that 40% of patients in France do not have inhaled corticosteroids in their treatment plans, yet she stressed that all should receive them. Leukotriene modifiers must not be used as a substitute for ICS.

Lowest Effective ICS Dose

“The right dose of ICS is the lowest possible dose that allows for asthma control and risk management,” said Chenivesse, “and this is most often a low dose, the first step in asthma maintenance therapy. Its definition is not based on a strict pharmacodynamic effect but on the proportion of the maximum effect achieved. Each molecule reaches its maximum effect, but more than 80%-90% of this effect is achieved very quickly, even at low doses.”

Note that low doses are not equivalent across different molecules. Switching from one inhaled corticosteroid to another, even at low doses, can significantly alter the anti-inflammatory effect. “Thus, low doses of each inhaled corticosteroid are not equivalent in terms of clinical efficacy, as specified in the GINA 2025 update (page 71),” warned Chenivesse.

Daily vs As-Needed Strategy

The question of whether to use a low-dose ICS daily (morning and evening) or as needed (when the patient is symptomatic), in combination with formoterol, has recently been raised, with clear answers: ICS-formoterol as needed is noninferior to daily budesonide for reducing the risk for severe exacerbations. In contrast, daily budesonide is more effective than as-needed budesonide combined with formoterol for symptom control (44.4% vs. 34.4% of weeks with good control) and for respiratory function.

Escalation Beyond Increasing ICS

As Chenivesse pointed out, “The growing range of pharmacological and nonpharmacological treatments allows for a step-up strategy independent of increasing the ICS dose, by tailoring management to each patient’s phenotype and situation.”

Indeed, increasing the dose of inhaled corticosteroids provides very limited clinical benefit while carrying an increased risk for adverse effects.

According to GINA 2025, after a low dose of inhaled corticosteroids, treatment escalation should not rely mainly on increasing the dose. Management must — at every visit, and even more so if the patient is not well controlled, as Chenivesse explained — systematically address modifiable risk factors and comorbidities, with particular emphasis on environmental control and on optimizing inhalation technique, including smoking cessation, weight management, and respiratory rehabilitation.

Allergen Immunotherapy and Long-Acting Beta Agonist (LABA)

Chenivesse noted that this personalized approach is still seldom used in practice, but added that in patients with a respiratory allergy to house dust mites accompanied by allergic rhinitis, and whose asthma is only partially controlled (Asthma Control Questionnaire [ACQ] score 1-1.5), adding house dust mite allergen immunotherapy to low-dose ICS improves symptom control and reduces the risk for exacerbations.

In other situations, following low-dose ICS, the addition of a long-acting bronchodilator is a therapeutic option for medication intensification. A LABA must be prescribed as a fixed-dose combination with an inhaled corticosteroid within the same device.

Numerous studies show that adding a LABA improves asthma control and is more effective than doubling the ICS dose, a strategy long in use.

Furthermore, an interesting strategy, particularly for managing the risk for exacerbations — “background and symptoms” — reduces the risk for severe exacerbations at the same ICS dose (low-dose combined with formoterol) compared with doubling the ICS dose. Chenivesse explained: “This involves one dose in the morning and one in the evening, plus one or two additional doses in case of breathing difficulties. This provides a rescue treatment containing ICS because symptoms indicate persistent airway inflammation. In that case, we take the opportunity to discontinue short-acting bronchodilators such as salbutamol and terbutaline.”

And Then?

At steps 4 and 5, treatment escalation primarily relies on a medium dose of ICS, always combined with a LABA. Before considering a high dose or further escalation, the addition of a second long-acting bronchodilator, a long-acting muscarinic antagonist (LAMA), may be proposed (moderate-dose ICS-LABA-LAMA). The goal is to limit the use of high doses of ICS as much as possible by maintaining treatment around an effective moderate dose.

Managing ICS Tapering Safely

ICS tapering may be considered in a patient whose asthma has been “perfectly controlled for at least 1 year,” who is treated with a moderate-to-high dose of ICS combined with at least one additional maintenance therapy, and who has no exacerbation risk factors, the specialist noted.

But be careful — “stopping ICS is never an option,” she warned. In practice, the strategy involves a gradual 50% reduction in the ICS dose while maintaining other maintenance therapies.

One option is to use biologic therapy, indicated for patients with severe exacerbations or corticosteroid dependence. In the SHAMAL study, which evaluated tapering ICS while on benralizumab, a change in the ACQ-5 score was seen in 74% vs 70% of patients vs control individuals. There was no difference in the risk for severe exacerbation between the groups (relative risk, 1.05; 95% CI, 0.41-2.68). “Although it is likely still beneficial to keep a low dose of ICS to preserve forced expiratory volume in 1 second,” she noted.

This story was translated from Medscape’s French edition.