Both the 2025 GOLD and GINA guidelines for COPD and asthma, respectively, do not address concomitant use of inhaled corticosteroids (ICS) and systemic corticosteroids. While in the GOLD guidelines, exacerbations of COPD may require treatment using systemic corticosteroids that could overlap with current ICS, this is an acute phase of treatment and not meant for routine exposure. GOLD does not recommend systemic corticosteroids for more than 5 days, which includes hospital exposure. The same principle applies within the GINA guidelines which recommends systemic corticosteroids primarily for moderate or severe exacerbations, especially if patients fail to respond to ICS-containing medications. However, GINA does provide slightly more context, suggesting systemic corticosteroids can be continued for 5-7 days in adults, or 3-5 days in children post-exacerbation. During this time, maintenance ICS-containing medication dose may be increased in the next 2-4 weeks, meaning that concomitant exposure is possible in this timeframe. [1], [2]
Systemic corticosteroids remain the cornerstone of treatment for acute asthma exacerbations, and the routine addition of ICS has not been shown to provide consistent additional benefit when systemic corticosteroids are already administered. Evidence from randomized controlled trials summarized in two Cochrane systematic reviews demonstrates that the concomitant use of ICS with systemic corticosteroids did not result in statistically significant reductions in relapse rates, hospital admissions, symptom scores, quality of life, or adverse events compared with systemic corticosteroids alone in patients treated for acute asthma and discharged from the emergency department (ED). Similarly, when ICS were administered early in the ED setting alongside systemic corticosteroids, subgroup analyses showed conflicting evidence regarding reductions in hospital admissions, and there was insufficient evidence of clinically important improvements in pulmonary function or clinical outcomes attributable to concomitant therapy. Although ICS therapy reduced hospital admissions when compared with placebo in patients not receiving systemic corticosteroids, and modest improvements in pulmonary function were observed in some analyses, these benefits were not consistently demonstrated when ICS were used in addition to systemic corticosteroids. Both systematic reviews concluded that there is insufficient evidence to support the routine concomitant use of inhaled and systemic corticosteroids in acute asthma management, and further research is needed to clarify their role when used together. [3], [4]
A 2020 meta-analysis evaluated the efficacy of ICS in the treatment of acute asthma exacerbations in ED settings, including their use in addition to systemic corticosteroids (SCS). The analysis included 25 randomized controlled trials involving 2,733 participants and compared ICS plus SCS versus SCS alone as the primary comparison. The addition of ICS to SCS was associated with a statistically significant reduction in hospital admission rates compared with SCS alone, with a fixed-effects odds ratio (OR) of 0.73 (95% confidence interval [CI] 0.57 to 0.94), based on seven studies involving 1,433 participants. Lung function outcomes were inconsistently reported and did not consistently demonstrate statistically significant differences; however, moderate evidence indicated improvements in clinical scores and vital signs with the addition of ICS to SCS. Adverse events were infrequently reported and were primarily limited to mild symptoms such as nausea and vomiting. The authors concluded that there is moderate evidence supporting the efficacy of high-dose ICS administered in addition to SCS in reducing hospital admission rates in patients presenting with moderate-to-severe acute asthma exacerbations in the ED, although heterogeneity among studies and limitations in reported outcomes were noted, and further research is needed to define the optimal role of ICS in both ED and outpatient settings. [5]