Stepping down asthma treatment is a way to manage patients over time. There can be benefit or harm by stepping down asthma medication. Many factors need to be considered which I will discuss ahead.
Asthma is a chronic inflammatory airway disease related to genetic and environmental factors. A stepwise approach by the National Asthma Education and Prevention Program has been advocated. Individuals who have poor control are at high risk for exacerbations and patients with good asthma control are at low risk for exacerbation and are candidates to “step down”. The most recent guidelines suggest to step down when asthma has been controlled for 3 months, with a reduction of corticosteroid dose between 25-50%.
Reasons to step down asthma therapy are to decrease potential long term side effects of medications. Although asthma medications are generally safe and well tolerated long term, there are potential side effects. Also, patients may prefer to avoid medications. Cost also can be a factor due to the Affordability Care Act, where many costs have been pushed to the consumer including medications.
Stepping down asthma medication may lead to an increased risk of an exacerbation. The risk of stepping down from a combined inhaled corticosteroid-long term beta agonist (ICS-LABA) to an ICS is not well characterized and needs to be studied more.
Reducing the ICS dose can be accomplished by changing the frequency to once daily from twice daily or reducing the overall dose 25-50% percent.
Changing from an ICS to Singulair, can lead to a treatment failure (30%), a recent study showed.
Any method of stepping down therapy may be safe options for patients with stable asthma, however there is additional risk of exacerbations than just continuing the current asthma medication type and dose.
Stepping down therapy may not be needed if patients were started on a lower step of asthma care. Studies have shown there is only a very small benefit of starting high-dose ICS when treating asthma.
Before stepping up, assess for factors that may be interfering with treatment response, (adherence, technique, allergy triggers). Before stepping down, the risks and benefits need to be discussed with the patients. Lung function or pulmonary function testing should be assessed.