Step-down Therapy in Asthma: What Is the Optimal Approach?

Current asthma guidelines recommend a step-up approach when using pharmacologic therapy to control asthma and then stepping down therapy once asthma control is maintained for at least 3 months. Reducing treatment is straightforward in those using inhaled corticosteroids (ICS) alone, but the optimal approach to reducing therapy in patients with moderate to severe asthma treated with combination ICS and long-acting beta-agonists (ICS/LABA) is unclear, especially since controversy over the safety of LABAs continues.

In February 2010, the US Food and Drug Adminstration recommended that LABAs should be used for the shortest time needed to achieve asthma control and then be discontinued. These recommendations did not specify timing of such an approach to adding and stepping down therapy, and this issue has not been well studied in clinical trials. This has left clinicians confused as to how to best approach step-down of ICS/LABA-treated patients, since currently available data suggest that the preferred strategy is to reduce the ICS dose prior to discontinuing the LABA (Fowler et al. J Allergy Clin Immunol. 2002;109[6]:929; Bateman et al. J Allergy Clin Immunol. 2006;117[3]:563; Reddel et al. Respir Med. 2010;104[8]:1110; Godard et al. Respir Med. 2008;102[8]: 1124). So, do these studies answer this question definitively? Unfortunately, the answer is no. These studies were of limited duration, so it is unclear if asthma control was maintained following de-escalation of treatment. Moreover, not all of these studies ascertained that patients remained symptomatic receiving low to moderate dose ICS alone, and were, thus, treated according to current recommendations for use of LABAs. Further studies that compare these two different strategies for step-down therapy in moderate to severe asthma appear warranted.

Dr. Linda Rogers, FCCP
Steering Committee Member