Are Inhaled Corticosteroids Overused in Mild Asthma Cases?

Reassessing Risk-Benefit in Light of Evolving Guidelines and Real-World Practice

The use of inhaled corticosteroids (ICS) has long stood as a foundational element of asthma management. Their efficacy in dampening airway inflammation, reducing exacerbation frequency, and improving pulmonary function is well supported by evidence. However, over the past several years, a growing body of research and updated clinical guidelines have prompted a re-examination: Are we overprescribing ICS for patients with mild asthma?

This question doesn’t challenge the value of ICS but rather seeks precision in their deployment. In patients whose asthma symptoms are intermittent or mild, the long-term use of daily ICS may offer marginal benefit while exposing them to unnecessary side effects. Furthermore, emerging strategies—such as as-needed ICS-formoterol—are changing how we approach mild asthma management.

For clinicians and medical students navigating asthma care, this topic warrants a deeper, evidence-based discussion.

Defining Mild Asthma: More Than Just Infrequent Symptoms

Asthma, as we now understand it, is a heterogenous and dynamic disease. The term "mild asthma" may suggest simplicity, but in practice, it's often poorly defined. According to the Global Initiative for Asthma (GINA):

• Symptoms occur fewer than twice per week
  
  
• No more than two night-time awakenings per month
  
  
• Lung function remains normal between episodes
  
  
• Exacerbations are rare or absent
  

While the above criteria appear clear, they may mislead in practice. Patients often underreport symptoms, normalize limitations, or misattribute exacerbations. As a result, labeling asthma as “mild” may lead to either over-treatment or under-treatment, depending on the clinician’s perception and the patient's communication.

The Traditional Approach: Daily Low-Dose ICS

Historically, low-dose daily ICS has been recommended even for patients with infrequent symptoms. The rationale stems from key pathophysiological observations:

• Inflammation is present even in clinically mild asthma
  
  
• ICS reduce airway hyperresponsiveness and chronic remodeling risk
  
  
• Prophylactic ICS reduces the likelihood of severe exacerbations, including those requiring hospitalization
  

Despite these benefits, the real-world implementation has limitations. Many patients with mild symptoms are non-adherent to daily ICS regimens, particularly when they feel well most of the time. Research consistently finds that adherence to ICS in mild asthma is low—often below 40%. This discrepancy between prescription and usage raises an important question: Are we offering a treatment that patients neither value nor follow?

Overuse vs. Appropriate Use: The Clinical Dilemma

When discussing “overuse,” it’s not a critique of the therapy’s efficacy, but rather its blanket application without adequate stratification. Key concerns include:

• Prescribing ICS without individualized risk assessment
  
  
• Chronic use in patients unlikely to benefit from daily therapy
  
  
• Exposure to avoidable side effects over time
  

Even low-dose ICS carries potential adverse effects, such as:

• Hoarseness and voice changes
  
  
• Oral candidiasis
  
  
• Potential growth deceleration in pediatric patients
  
  
• Possible impact on bone density with long-term use
  

These considerations become more relevant when the patient only experiences seasonal symptoms or has clear triggers that can be avoided or addressed otherwise. It forces us to ask: Are we treating the condition or managing risk inappropriately?

Evidence for Intermittent or As-Needed ICS Use

In recent years, robust clinical trials have tested new strategies that reflect real-world behavior more closely. Two pivotal studies are:

SYGMA 1 & SYGMA 2 Trials (2018)
These landmark randomized controlled trials compared:

• Daily ICS (budesonide)
  
  
• As-needed ICS-formoterol (a fast-acting β2-agonist and steroid combination)
  
  
• Placebo (in SYGMA 1)
  

Findings demonstrated:

• As-needed ICS-formoterol significantly reduced severe exacerbations, nearly equaling daily ICS
  
  
• Symptom control was slightly better with daily ICS but not significantly in clinical practice terms
  
  
• Patients favored the convenience and reduced medication burden of as-needed regimens
  

These trials validated what many clinicians suspected: In select mild asthma cases, intermittent ICS may be sufficient.

The Novel GINA Guidelines Shift

In response to this new evidence, GINA revised its long-standing approach in 2019. The organization no longer supports the use of short-acting β2-agonists (SABA) alone for symptom relief in mild asthma. Instead, it recommends:

• As-needed low-dose ICS-formoterol for patients with infrequent symptoms
  
  
• Alternatively, taking ICS concurrently with SABA when symptoms arise
  

This represents a paradigm shift. Rather than emphasizing daily ICS for everyone, GINA now acknowledges behavioral patterns and newer outcomes data, promoting safety without unnecessary treatment burden.

Why Some Doctors Still Prescribe Daily ICS

Despite this shift, the use of daily ICS in mild asthma remains widespread. Several reasons explain this persistence:

• Training and inertia: Many clinicians were taught a stepwise escalation model emphasizing early ICS use
  
  
• Concerns about unpredictable exacerbations, especially in pediatric patients
  
  
• Guideline variability: Not all national protocols have adopted GINA’s updates
  
  
• Patient psychology: Some patients find comfort in structured daily therapy
  
  
• Insurance and access: Combination relievers like ICS-formoterol may be less accessible or more expensive
  

This indicates that the ongoing use of daily ICS in mild asthma is not necessarily due to misinformation, but rather a complex web of clinical caution, systemic limitations, and practical logistics.

Patient Factors Contributing to Overuse

Physician prescription patterns aren’t the sole contributor to ICS overuse. Patients may inadvertently perpetuate the cycle by:

• Requesting continued refills without proper follow-up
  
  
• Using ICS prophylactically due to anxiety about symptoms
  
  
• Applying inhalers inappropriately for symptoms not caused by asthma
  
  
• Misinterpreting upper airway symptoms (e.g., allergic rhinitis or laryngeal spasm) as asthma
  

Furthermore, in some populations, asthma may be overdiagnosed. Conditions such as vocal cord dysfunction, panic-induced dyspnea, and non-asthmatic eosinophilic bronchitis may mimic asthma and prompt inappropriate ICS initiation.

The Role of Diagnostic Reevaluation

To avoid unnecessary ICS exposure, clinicians should reassess before initiating or escalating long-term therapy. This includes:

• Confirming the diagnosis with objective measures: spirometry, peak expiratory flow variability, or fractional exhaled nitric oxide (FeNO) where available
  
  
• Evaluating inhaler technique and adherence
  
  
• Identifying comorbid conditions such as allergic rhinitis, GERD, or obesity-related dyspnea
  
  
• Assessing environmental exposures or occupational triggers
  

This targeted approach allows for more accurate treatment decisions and avoids masking non-asthmatic pathologies with unnecessary ICS use.

Alternative Non-ICS Strategies in Mild Asthma

Although ICS remains the gold standard for anti-inflammatory control, several non-ICS options can serve specific patient subgroups with mild disease:

• Allergen immunotherapy: Particularly useful when a specific allergen is identified as a trigger
  
  
• Montelukast: A leukotriene receptor antagonist, with modest efficacy but ease of oral administration
  
  
• Nasal corticosteroids: Beneficial in upper airway-driven asthma mimics or overlapping allergic rhinitis
  
  
• Lifestyle interventions: Smoking cessation, weight management, and physical activity can significantly impact symptom control in select patients
  

While none of these replace ICS entirely, they offer valuable adjuncts or alternatives in appropriately selected individuals.

Key Takeaways for Clinical Practice

ICS have dramatically improved outcomes in asthma care, but their use in mild cases should be nuanced rather than automatic. Core points include:

• Not all mild asthma requires daily ICS, particularly when symptoms are rare and predictable
  
  
• Overuse can lead to side effects, cost-related burdens, and poor adherence
  
  
• Updated guidelines such as GINA now support as-needed strategies, reflecting both patient behavior and trial data
  
  
• Physician education, diagnostic precision, and patient engagement remain central to optimal management
  
  
• A one-size-fits-all approach is no longer appropriate in modern asthma care
  

Ultimately, managing mild asthma in 2025 and beyond requires flexibility, vigilance, and open communication. The era of personalized medicine invites us to weigh the full picture—clinical data, patient lifestyle, and emerging science—before reflexively reaching for the prescription pad.