Stepping Down Asthma Treatment

Good news, treatment works in two directions up and down. I have to admit that until recently, I have only have had a brief experience with stepping down treatment but it does happen. I was happy to learn that stepping down treatment is part of the essential goals of asthma therapy, along with achieving complete or (near complete) disease control while minimizing the adverse effects of the therapies used. 1

What are the specific goals of stepping down treatment? 3

  • Prevent chronic and troublesome symptoms
  • Provide optimal pharmacotherapy with minimal or no adverse effects
  • maintain (near) normal lung function
  • maintain normal activity levels (including exercise)
  • Prevent recurrent exacerbations
  • Minimize (or eliminate) emergency department visits and hospitalizations
  • Provide optimal pharmacotherapy with minimal or no adverse effects
  • Meet patients'and families' expectations of and satisfaction with asthma care.

What are the factors that are involved in reducing asthma medication?

Here are a few fun facts that I found while learning more about stepping down medications. The guidelines do not take into consideration  individual responses to medication. Bingo!, individual responses, I completely forgot about this factor. This element just seems to fade into the background when you have found a medication regime that works for you  but I certainly remember getting to this stage took some trial and error and individual response was part of that process. There is significantly more data and studies on "step up" guidelines or protocols than there is on "step down" guidelines. At this stage there is no consensus on the perfect approach for stepping down treatment.

Guidelines suggest that asthma medication should be reduced once asthma control is sustained. When you have reached this stage typically moderate dose inhaled corticosteroids (ICS) may be reduced. Reachers still have unanswered questions about the lowest effective ICS dose and the role of non-ICS controllers in treatment reduction. 1 Long acting beta agonist (LABA) safety concerns have created controversy about how to step down patients on ICS/LABA therapy. 1

There are some suggestions that stepping down therapies begins with eliminating the last medication that  was added  and  then reducing the ICS. There are thoughts that adding adjunctive therapies might allow for more effective reduction in ICS. 3 While many patients may experience a reduction in ICS, studies have confirmed that ongoing therapy with ICS is necessary to maintain asthma control; patients in whom ICSs were completely withdrawn had a prompt return of symptoms.4,5

It is important to remember that every patient is different and individual plans are necessary and developed with your care team. Identifying patients who are candidates for "step down" therapy is less obvious and physicians are hopeful for the development of features that would more clearly predict a stepwise of which patients step down would be most successful in.


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