The risk of asthma exacerbation after reducing inhaled corticosteroids: a systematic review and meta‐analysis of randomized controlled trials

<jats:title>Abstract</jats:title><jats:sec><jats:title>Background</jats:title><jats:p>Asthma guidelines suggest reducing controller medications when asthma is stable.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>The purpose of the study is to estimate the risk of asthma exacerbation in stable asthmatics who reduce inhaled corticosteroids (<jats:styled-content style="fixed-case">ICS</jats:styled-content>) compared to those who maintain a stable <jats:styled-content style="fixed-case">ICS</jats:styled-content> dose. We identified articles from a systematic review of <jats:styled-content style="fixed-case">E</jats:styled-content>nglish and non‐<jats:styled-content style="fixed-case">E</jats:styled-content>nglish articles using <jats:styled-content style="fixed-case">MEDLINE</jats:styled-content>,<jats:styled-content style="fixed-case"> EMBASE</jats:styled-content>, Web of Science, and <jats:styled-content style="fixed-case">CENTRAL</jats:styled-content> (inception to <jats:styled-content style="fixed-case">M</jats:styled-content>ay 25, 2013). We included randomized controlled trials (<jats:styled-content style="fixed-case">RCT</jats:styled-content>s) with a stable asthma run‐in period of 4 weeks or more, an intervention to reduce <jats:styled-content style="fixed-case">ICS</jats:styled-content>, and a follow‐up period of at least 3 months.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>The search strategy identified 2253 potential articles, of which 206 were reviewed at the full‐text level and 6 met criteria for inclusion. The relative risk of an asthma exacerbation in individuals who reduced <jats:styled-content style="fixed-case">ICS</jats:styled-content> compared to those who maintained the same <jats:styled-content style="fixed-case">ICS</jats:styled-content> dose was 1.25 (95% <jats:styled-content style="fixed-case">CI</jats:styled-content> 0.96, 1.62; <jats:italic>P</jats:italic> = 0.10; <jats:italic>I</jats:italic><jats:sup>2</jats:sup> = 0%) in studies with a mean follow‐up of 22 weeks. Individuals who reduced <jats:styled-content style="fixed-case">ICS</jats:styled-content> had a decreased% predicted <jats:styled-content style="fixed-case">FEV</jats:styled-content><jats:sub>1</jats:sub> of 0.87% (95% <jats:styled-content style="fixed-case">CI</jats:styled-content> −1.58%,3.33%; <jats:italic>P</jats:italic> = 0.49, <jats:italic>I</jats:italic><jats:sup>2</jats:sup> = 58%) and a decreased mean morning peak expiratory flow of 9.57 l/min (95% <jats:styled-content style="fixed-case">CI</jats:styled-content> 1.25, 17.90; <jats:italic>P</jats:italic> = 0.02; <jats:italic>I</jats:italic><jats:sup>2</jats:sup> = 74%) compared to those individuals who maintained a stable <jats:styled-content style="fixed-case">ICS</jats:styled-content> dose.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Asthma exacerbations were statistically no more likely among individuals who reduced <jats:styled-content style="fixed-case">ICS</jats:styled-content> compared to those who maintained their <jats:styled-content style="fixed-case">ICS</jats:styled-content> dose, supporting current guidelines which recommend decreasing <jats:styled-content style="fixed-case">ICS</jats:styled-content> by 50% after a period of asthma stability.</jats:p></jats:sec>