As-needed inhaled corticosteroids in asthma: an Official American Thoracic Society clinical practice guideline

BACKGROUND: Inhaled corticosteroid (ICS)-containing reliever therapy has demonstrated efficacy in improving asthma outcomes when compared to short-acting beta2-agonists (SABA) alone but remains underutilized. The purpose of this guideline is to provide recommendations surrounding the use of combination ICS-formoterol or ICS+SABA (in combination or separate inhalers) as reliever therapy across the asthma severity spectrum in adolescents and adults. METHODS: The American Thoracic Society clinical practice guideline panel evaluated six research questions in the PICO format addressing the use of ICS-containing reliever therapy across National Asthma Education and Prevention Program (NAEPP) asthma treatment steps 1-5. The methodology team conducted systematic literature reviews and GRADE assessments, which the panel utilized to inform the recommendations for each specific PICO and overall. RECOMMENDATIONS: In patients at NAEPP steps 1 and 2, the panel made strong recommendations for the use of as-needed-only ICS-SABA or ICS-formoterol over SABA-only therapy, and conditional recommendations over scheduled ICS + as-needed SABA. In patients at NAEPP steps 3-5, the taskforce made a strong recommendation for the use of maintenance-and-reliever therapy (MART) with ICS-formoterol over scheduled ICS-LABA plus as-needed SABA. In patients at NAEPP steps 3-5 who are using scheduled maintenance ICS-LABA, the panel made a conditional recommendation for use of ICS+SABA reliever over SABA reliever. In considering these recommendations, the panel valued the importance of preventing severe exacerbations and considered the risk of SABA-only treatment, as well as ICS and systemic corticosteroid (SCS) exposure. CONCLUSIONS: This clinical practice guideline, informed by systematic reviews and GRADE-based appraisals of PICO-framed evidence, makes these evidence-based recommendations for the safe and effective use of ICS-containing reliever therapy in asthma.

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Publication Details

Journal
American Journal of Respiratory and Critical Care Medicine
Published
2026-11-03
DOI
https://doi.org/10.1093/ajrccm/aamag577
Primary Topic
Asthma and respiratory diseases
Type
article
Field-Weighted Citation Impact
0.00
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article

As-needed inhaled corticosteroids in asthma: an Official American Thoracic Society clinical practice guideline

Alex Robert Jenkins, Juan Carlos Cardet, Nizar N. Jarjour, Charlie Strange et al.
American Journal of Respiratory and Critical Care Medicine
Asthma and respiratory diseases
article

As-needed inhaled corticosteroids in asthma: an Official American Thoracic Society clinical practice guideline

Alex Robert Jenkins, Juan Carlos Cardet, Nizar N. Jarjour, Charlie Strange, Helen Kathryn Reddel, Sunita Sharma, Christopher M. Kearney, N. Solanki, Njira Lucia Lugogo, Paul M. O’Byrne, Shandra Lee Knight, Tina V. Hartert, Sandhya Khurana, Elliot Israel, Praveen Akuthota, Mark A. Aronica, Richard Paul Ramonell, Rodolfo M. Alpizar-Rivas, Ashley Losier, O’Neil Green, Melody G. Duvall, Arjun Mohan, Neha Solanki, Immunology and Inflammation the American Thoracic Society Assembly on Allergy, Sunita Sharma, Glen G Stevenson
article en

Abstract

BACKGROUND: Inhaled corticosteroid (ICS)-containing reliever therapy has demonstrated efficacy in improving asthma outcomes when compared to short-acting beta2-agonists (SABA) alone but remains underutilized. The purpose of this guideline is to provide recommendations surrounding the use of combination ICS-formoterol or ICS+SABA (in combination or separate inhalers) as reliever therapy across the asthma severity spectrum in adolescents and adults. METHODS: The American Thoracic Society clinical practice guideline panel evaluated six research questions in the PICO format addressing the use of ICS-containing reliever therapy across National Asthma Education and Prevention Program (NAEPP) asthma treatment steps 1-5. The methodology team conducted systematic literature reviews and GRADE assessments, which the panel utilized to inform the recommendations for each specific PICO and overall. RECOMMENDATIONS: In patients at NAEPP steps 1 and 2, the panel made strong recommendations for the use of as-needed-only ICS-SABA or ICS-formoterol over SABA-only therapy, and conditional recommendations over scheduled ICS + as-needed SABA. In patients at NAEPP steps 3-5, the taskforce made a strong recommendation for the use of maintenance-and-reliever therapy (MART) with ICS-formoterol over scheduled ICS-LABA plus as-needed SABA. In patients at NAEPP steps 3-5 who are using scheduled maintenance ICS-LABA, the panel made a conditional recommendation for use of ICS+SABA reliever over SABA reliever. In considering these recommendations, the panel valued the importance of preventing severe exacerbations and considered the risk of SABA-only treatment, as well as ICS and systemic corticosteroid (SCS) exposure. CONCLUSIONS: This clinical practice guideline, informed by systematic reviews and GRADE-based appraisals of PICO-framed evidence, makes these evidence-based recommendations for the safe and effective use of ICS-containing reliever therapy in asthma.

American Journal of Respiratory and Critical Care Medicine
Boston University (US), Brigham and Women's Hospital (US), Boston Children's Hospital (US), Hartford Hospital (US), Cleveland Clinic (US), University of Wisconsin–Madison (US), Harvard University (US), Medical University of South Carolina (US), University of Pittsburgh (US), University of South Florida (US), University of Michigan (US), Woolcock Institute of Medical Research (AU), Yale University (US), University of California San Diego (US), Wisconsin Division of Public Health (US), Wake Forest University Health Sciences (US), Wake Forest University (US), University of Colorado Anschutz Medical Campus (US), University of Rochester (US), Vanderbilt University Medical Center (US), McMaster University (CA)
Openalex Percentile: Top 14%
Asthma and respiratory diseases
DOISourceOpenAlex
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