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Background: COPD guidelines report that systemic corticosteroids are preferred over inhaled corticosteroids in the treatment of exacerbations, but the inhaled route is considered to be an optionif the acute exacerbations are controlled by corticosteroids, such as at a single dose [20]. In contrast, no studies report the use of systemic steroids and inhaled corticosteroids for the management of acute exacerbations after non-severe asthma exacerbations, except for the recent observation that systemic steroids may be considered in patients with asthma who have severe persistent symptoms after an acute exacerbation [15,21]. A total of 7 studies were identified ( Figure 2 ). 7 of these were double-blind randomized controlled trials (Cochrane summary, Table 5 ). Seven of these studies were rated as low evidence (Cochrane summary, Table 5 ). The remaining studies were rated as moderate evidence (Cochrane summary, Table 5 ). In all studies, short-term systemic corticosteroids were included in their treatment. Of the 14 studies (5 RCTs) that included patients with asthma who completed the study, 1 was rated low evidence ( Figure 1 ), 3 were rated moderate evidence ( Table 5 ), and a single study was rated as low evidence/moderate evidence ( Table 5 ). The 8 studies in detail are shown in Figure 1 . Discussion The first evidence to show that inhaled systemic steroids may be used in acute exacerbations after mild or moderate acute exacerbations, followed by a repeat evaluation by an expert consultation, suggests that there may be a potential utility in initiating systemic steroid administration when there is an acute asthma exacerbation. The safety of systemic steroids is well established and this evidence suggests they may provide a short-term option for managing asthma exacerbations which may cause further exacerbations. However, further large population and trial studies are needed to demonstrate the long-term long-term safety of inhaled systemic steroids. Study 1 A retrospective cohort cohort study assessing the long-term safety of systemic corticosteroid administration in patients with newly diagnosed moderate asthma for the first time compared the use of systemic steroid to the use of inhaled steroids in a subsequent evaluation for the development of persistent exacerbations at 2 years of follow up [14]. The study did not have details of asthma exacerbations. After a total of 10,843 patients from 8 studies with 9,273 patients from randomised controlled trials were included, 3 RCTs comparing the use of inhaled steroids to systemic steroid, and 8 RCTs comparing the use of systemic corticosteroids to inhaled corticosteroids were rated as low evidence, as were two meta-analyses with 6 Similar articles:

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