Inhaled steroids in addition to systemic steroids in asthma exacerbations ? WHAT !!

Another pulmonary topic ! Please don't get bored of pulm now. Two more weeks of pulm and then I'll be in MICU.

CASE STORY : 

• We were consulted for a basic bread and butter Asthma exacerbation in a middle aged obese African American women. Patient had a history of intermittent asthma at home, taking only prn albuterol. 
• We were doing all the usual right things with nebulizers, IV solumedrol, antibiotics etc. The only difference this time was, I had a new question that didn't occur to me for the last 2.5 yrs of residency. Blame me!
• Prior to admission, the patient was not on inhaled corticosteroid (ICS). She is now on IV solumedrol 80mg TID for the acute exacerbation.

CLINICAL QUESTIONS !

1. DO I START AN INHALED CORTICOSTEROID (ICS) IN ADDITION TO SYSTEMIC CORTICOSTEROID (SCS) ?
2. IS THERE ANY BENEFIT ?
3. WHAT IS THE EVIDENCE BEHIND THIS TOPIC?

REVELATION : 

• For the last 2.5 yrs, I never added an ICS when the patient was being treated with SCS. Makes total sense right ?! Why would the patient need additional ICS when she is getting SCS. I never tried to look up evidence till today.
• Well, turns out that adding ICS to SCS showed improved outcomes in asthma exacerbations.
• There was a well designed RCT by Rowe et al, published in JAMA that looked at this exact clinical question. Adding ICS to SCS during an exacerbation reduced the relapse rates, improved the quality of life, reduced the frequency of rescue albuterol use.

Few limitations that might question the clinical applicability of these results are:

• There are no other studies that looked at this clinical question. These results need to be replicated in future studies to confidently apply the conclusions in clinical practice.
• This study was limited to Asthma patients who were only on prn albuterol prior to admission (patients on ICS or SCS prior to admission were excluded). So results may not be equated to other patient populations. 
• Patients in this study were not treated inpatient. They were discharged from ER on ICS + SCS. So, we aren't sure if this would be applicable to inpatient population. 

WOULD THIS EVIDENCE CHANGE MY PRACTICE?

• Starting today, I will definitely add ICS to SCS when a patient is admitted for asthma exacerbation (specially those who weren't on ICS prior to admission). 
• They should be discharged on ICS along with the SCS burst/taper. At outpatient follow-up, based on the patients clinical status, we could step-down from ICS if necessary. 
• I guess it may also be ok not to start an ICS - due to the above mentioned limitations. 
• Well, there is one good study :) Change has to begin somewhere! 

A MORE COMMON SCENARIO : 

• The asthma exacerbation patients we usually admit are already on ICS prior to admission. 
• When these patients come in for an exacerbation, no one knows whether continuing ICS in addition to SCS would improve outcomes. 
• Pulmonary team attendings at our institution go either ways (Few are ok with holding the ICS while patients are on SCS, while others are very particular about continuing ICS in addition to SCS). 
• Even in this patient group, my personal opinion (extremely weak evidence, Probably Grade B/C recommendation :) is to continue the ICS in addition to SCS. There is no right / wrong answer. 

Pitch in your thoughts.

References:

1. Rowe BH1, Bota GW, Fabris L, et al. Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department: a randomized controlled trial. JAMA. 1999 Jun 9;281(22):2119-26.
2. ACP J Club. 2000 Jan-Feb;132(1):13.