Each year, more than 1.3 million individuals visit U.S. emergency departments (EDs) with asthma-related conditions.¹ Patients often present after being unable to manage their condition at home. Historically, short-acting beta agonists (SABAs), such as albuterol, have been used as a pillar of acute asthma management. These bronchodilators provide quick relief. For patients well enough to be discharged from the ED, emergency physicians generally ensure patients have access to an albuterol rescue inhaler and often prescribe a short course of steroids; however, this is not the best practice.

Shift in Guidance

Guidelines have been shifting during the past several years with regard to two specific medications—inhaled corticosteroids (ICS) and long-acting beta agonists (LABAs)—and now recommend ICS, which treat airway inflammation, as a part of rescue therapy. In fact, professional society recommendations cite overuse of SABAs and underuse of ICS inhalers as significant contributing factors to asthma morbidity.

For years, ICS inhalers containing fluticasone or budesonide have been a part of longterm treatment of persistent asthma due to their effect on inflammation and a substantially reduced risk for potential side effects compared with oral corticosteroids. In 2007, guidelines from the National Asthma Education and Prevention Program suggested that there may be a role for ICS, even if used intermittently. Moreover, the guidelines called out emergency clinicians specifically, recommending we should “consider initiating an ICS at discharge, in addition to oral systemic corticosteroids (Evidence B).”² In a 2020 update of the 2007 guidelines, ICS were recommended as a part of every treatment pathway with the exception of mild intermittent asthma, a category that some guidelines have eliminated altogether.^3,4

A recently published systematic review and network meta-analysis of 50,496 adult and pediatric patients from 27 randomized trials provided the overwhelming case for clinicians to ensure that patients with asthma are prescribed ICS.⁵ Network meta-analyses allow for comparison of outcomes among treatment groups where direct comparisons are limited or do not exist. This study found that inhalers containing ICS were associated with fewer severe exacerbations (i.e., had fewer systemic corticosteroids, ED visits, and/or hospitalizations) compared with SABAs alone. The risk ratio for ICS-formoterol was 0.63 (95 percent CI, 0.60-0.72) and was 0.84 (95 percent CI, 0.73-0.95) for ICS–SABA. ICS–formoterol therapy was associated with fewer asthma-related hospitalizations compared with SABAs, even when combined with ICS. No signal of increased harm resulted from either type of ICS therapy.⁵ The evidence is clear: We need to move away from SABA therapy alone.

Evidence Is Clear

Despite these recommendations, significant gaps exist in our treatment of patients with asthma—notably ICS prescribing rates. Filling quality gaps in medicine is tricky.

Inhaled corticosteroids are infrequently prescribed from the ED. This may be because ICS fall into the “it’s not my job” part of emergency medicine. We presume that a primary care physician will prescribe an ICS if clinically indicated; however, this isn’t always the case.

One study found that in patients treated in an ED for an asthma exacerbation, only a minority who were not prescribed an ICS at ED or hospital discharge and had a six-month follow-up visit received a prescription for an ICS at that follow-up visit.⁷ Inhaled corticosteroids and ICS–LABA therapy can also be expensive, and it can be technically difficult to navigate depending on a patient’s insurance coverage.

The data are clear, however: Regardless of the barriers, most of our ED patients with asthma would benefit and have fewer exacerbations if they were on an ICS. If we have difficulty initiating therapy, we should, at a minimum, urge patients to discuss starting an ICS (with or without a LABA) with their primary care physician.

Dr. Westafer (@Lwestafer) is assistant professor in the department of emergency medicine at the UMass Chan Medical School–Baystate and co-host of FOAMcast.

References

1. Fauvel AD, Southerland LT, Panchal AR, et al. Emergency department course of patients with asthma receiving initial emergency medical services care–perspectives from the National Hospital Ambulatory Medical Care Survey. J Am Coll Emerg Physicians Open. 2023;4(4):e13026.
2. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. J Allergy Clin Immunol. 2007;120(5 Suppl):S94-138.
3. Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP, et al. 2020 Focused Updates to the Asthma Management Guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146(6):1217-1270.
4. Global Initiative for Asthma. 2023 GINA Main Report. Published May 2, 2023. Accessed November 15, 2024.
5. Rayner DG, Ferri DM, Guyatt GH, et al. Inhaled reliever therapies for asthma: a systematic review and metaanalysis. JAMA. 2024:e2422700.
6. Kligler SK, Vargas-Torres C, Abbott EE, Lin MP. Inhaled corticosteroids rarely prescribed at emergency department discharge despite low rates of follow-up care. J Emerg Med. 2023;64(5):555-563.
7. Cydulka RK, Tamayo-Sarver JH, Wolf C, et al. Inadequate follow-up controller medications among patients with asthma who visit the emergency department. Ann Emerg Med. 2005;46(4):316-322.