Episode 365: 366. Association of dose of inhaled corticosteroids and frequency of adverse events

Bloom CI et al. Association of dose of inhaled corticosteroids and frequency of adverse events. Am J Respir Crit Care Med 2025 Jan; 211:54. (https://doi.org/10.1164/rccm.202402-0368OC)

Bloom and colleagues' study, published in the American Journal of Respiratory and Critical Care Medicine in January 2025, provides significant insights into the safety profile of inhaled corticosteroids (ICS) for asthma patients7. The research, which analyzed data from two large UK databases, reveals important associations between ICS dosage and adverse events.

GINA GUIDELINES+ step 1 is ics formoterol OR low dose ICS--- as you move up ICS is always in the picture like a bad ex girlfriend in the family picture…. You can never just cut it out—sure you can go on photo shop and make em bigger or smaller like you can go with ICS but you cant cut them out.

Key Findings

1. Low-dose ICS: No significant increase in adverse events7.
2. Medium to high-dose ICS: Associated with increased risks of:

• Major adverse cardiovascular events (MACE)
• Cardiac arrhythmia
• Pulmonary embolism (PE)
• Hospitalization for pneumonia71

1. Risk-Benefit Analysis:

• Absolute risk of adverse events was low
• Number needed to harm (NNH) for 12 months of ICS use:
• Medium dose (201-599 mcg): MACE (473), arrhythmia (567), PE (1221), pneumonia (230)
• High dose (≥600 mcg): MACE (224), arrhythmia (396), PE (577), pneumonia (93)3

1. Time-dependent risks:

• Highest risk observed at 12 months
• MACE risks increased in the first 60 days but returned to baseline after ICS cessation1

Implications for Asthma Management

1. Guideline adherence: Use the lowest effective ICS dose37.
2. Risk assessment: Consider patient-specific factors when prescribing medium to high-dose ICS.
3. Monitoring: Increased vigilance for potential adverse events in patients on higher ICS doses.
4. Step-down approach: Consider dose reduction once asthma is well-controlled1.
5. Alternative strategies: Explore options like low-dose ICS/formoterol for maintenance and relief, or biologics for frequent exacerbators1.

This study underscores the importance of balancing asthma control with potential risks of higher ICS doses. While ICS remain a cornerstone of asthma treatment, clinicians should aim for the lowest effective dose and regularly reassess the need for high-dose therapy.