A new guideline from the American College of Allergy, Asthma, and Immunology provides evidence-based recommendations for stepping down asthma medications for patients who have achieved sustained asthma control.
Stepping down asthma controller therapy allows clinicians to identify the minimum effective treatment needed to maintain wellness while reducing the burden of treatment with respect to adverse events, costs, and adherence, Bradley E. Chipps, MD, medical director of Capital Allergy and Respiratory Disease Center, in Sacramento, California, and colleagues report in the Annals of Allergy, Asthma and Immunology.
Although current practice guidelines suggest that medication should be reduced once symptoms have been controlled for at least 3 months, depending on the patient’s risk profile and initial level of severity, none have previously provided specific, evidence-based recommendations for when and how to do it, Chipps said in an interview.

Evidence-based guidelines

“Our goal through this document is to provide evidence-based guidelines on how to do it safely and properly to improve outcomes,” he said. “In reality, many patients are stepping down on their own, through non-adherence. At least if we arm physicians with this information, they can advise patients from the outset.”

The Asthma Controller Step-down Yardstick “is the final installment in our yardstick trifecta,” Chipps explained, referring to two previously published guidelines for stepping up controller therapy in adults and children with the disease.

According to the step-down guideline, clinicians should consider the following factors before implementing a step-down plan:
1.The patient’s current and previous levels of disease control, including the frequency and severity of previous deisease exacerbation.
2. The patient’s current and previous patterns of asthma control, such as seasonal variation.
3. Time since the patient’s last asthma exacerbation.
4. Factors contributing to symptom instability.
5. Potential barriers to success, such as a history of poor treatment adherence, lack of access to care, or lack of understanding

Therapeutic trial

For patients deemed appropriate candidates, “any step-down of asthma treatment should be considered as a therapeutic trial, with the outcome evaluated according to symptom control, lung function, and exacerbation frequency,” the authors write. “Exacerbation are a particularly significant measure; and may increase if treatment is stepped down too quickly or too far; even if symptoms appear to be reasonably controlled.”
For this reason, the authors stress that stepping down “should be considered a process; and not simply a jump from guideline-recommended treatment at one severity level to that at the next lower severity level. Multiple steps may be necessary to optimally step down from one severity level to the next. A partial step-down may be appropriate.”
Although the guidance document provides specific recommendations regarding appropriate medications; and dosing for patients on step 2 through step 5 asthma therapy; there is no one-size-fits-all step-down strategy, the authors write. But the approach for each patient should be individualizing; according to the patient’s current treatment, risk factors, values, and preferences.”