Stepping-down treatment in stable asthma should be individualized, ACAAI

The American College of Allergy, Asthma, and Immunology (ACAAI) has published a new guideline “Asthma Controller Step Down Yardstick” to help physicians decide when and how to step down asthma controller therapy according to guideline-defined control levels after the asthma symptoms improve and asthma is stable. The guideline outlines both reasons for, and reasons not to consider stepping down treatment, which should be “individualized according to the patients current treatment, risk factors, values, and preferences”.

As per the guideline, stepping down treatment should be considered to:

  • Re-assess a current diagnosis of asthma.
  • Decrease the potential adverse effects of asthma medications.
  • Address patient and family preferences about taking medications.
  • Reduce the burden of treatment (e.g., time to take medications, remembering to take medications, having to take medications at work or school).
  • Reduce treatment costs.
  • Simplify therapy and enhance adherence with treatment.

Consider not stepping down treatment when:

  • Reducing asthma medication may increase risk of asthma exacerbation or loss of control.
  • It is unclear whether the patient is using asthma medications as indicated.
  • A seasonal maintenance of therapy is needed (e.g., during the allergy season or viral season).

Stepping down from Step 2 treatment (ICS)

  • Patients who are likely to adhere to daily ICS treatment: Once-daily low-dose ICS monotherapy or once-daily low-dose ICS/long-acting beta-antagonist (LABA)
  • Patients who prefer an alternative to daily treatment or who may not adhere to daily treatment: Anti-inflammatory/reliever therapy with a combination ICS + fast-acting short-acting beta antagonist (SABA) or the LABA formoterol
  • Patients who prefer an oral medication or who have difficulty using an inhaler: Leukotriene modifier daily + SABA reliever (as-needed)

Stepping Down From Step 3 Treatment

For patients using an ICS/LABA combination

  • Decreasing the ICS dose by changing the number of puffs or frequency of dosing
  • Switching to a combination product with a lower ICS dose
  • Discontinuing the LABA while maintaining (and potentially tapering over time) the ICS dose

For patients using only an ICS

  • Decreasing the dose of ICS
  • Stepping down to a low-dose ICS/LABA
  • Using low-dose budesonide/formoterol  as maintenance and reliever medication (not FDA approved)
  • Patients with allergic asthma: Immunotherapy to further reduce ICS dose

 

Stepping Down From Step 4 Treatment

  • Consider step down only after a careful review of the patients history confirms a minimum of 6 months of asthma control and no exacerbations during the previous year.
  • For patients on ICS/LABA, reduce the dose of ICS while maintaining LABA.
  • Patients on tiotropium with ICS: Lower the dose of ICS while maintaining and possibly eventually discontinuing tiotropium if control is maintained.
  • Patients using tiotropium + ICS/LABA: Stop tiotropium while maintaining the ICS/LABA; wait at least 3 months between titration steps to ensure control is established.

Stepping Down From Step 5 Treatment

  • Objectively evaluating oral corticosteroids (OCS) and controller therapy use to determine adherence
  • Objectively evaluating responsiveness to a minimum 3-month trial of high-dose ICS/LABA under direct supervision
  • Initiating trial treatment with an appropriate biologic agent for a minimum of 4 to 6 months; assess asthma control and attempt to taper OCS over 2 to 4 months

The guideline is published online Dec. 12, 2018 in the Annals of Allergy, Asthma and Immunology

(Source: Medscape, EurekAlert)

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