Stepped adjustment of asthma therapy
Principles of stepped adjustment
The aim of stepped adjustment of asthma therapy is to establish the lowest dose of therapy that maintains asthma symptom control and prevents exacerbations. Most adults and adolescents with asthma have mild asthma that can be well controlled by Step 2 therapy; overtreatment with ICS+LABA combination therapy (Step 3 therapy) is common.
Assess asthma symptom control 1 to 3 months after starting or adjusting asthma therapy to determine whether therapy needs to be stepped up or down. Different clinical features of asthma respond to ICS therapy at different rates; waking due to asthma can improve after a week of ICS therapy, while lung function can take months to improve.
Before stepping therapy up or down, check what regimen the patient is using—it may not be the same as the regimen prescribed.
Update the patient’s written asthma action plan whenever treatment is changed.
Stepping up therapy
Stepping up asthma therapy can be considered if asthma symptom control remains partial or poor. Before stepping up therapy:
- confirm that symptoms are due to asthma
- assess inhaler technique
- assess adherence
- identify and manage any comorbid conditions that may be reducing asthma symptom control
- ensure that exposure to triggers is minimised.
Stepping down therapy
Stepping down asthma therapy can be considered if asthma is stable and well controlled for 2 to 3 months (see Assessing asthma symptom control). Assess the patient’s risk factors for exacerbations (see Risk factors for adverse asthma outcomes in adults and adolescents) and manage or minimise any modifiable risk factors. Avoid stepping down therapy when the patient has an acute respiratory infection, or when the patient’s access to medical services is likely to be limited (eg while travelling).
To step down therapy:
- For a patient taking a medium- or high-dose ICS (either as monotherapy or in combination with a LABA), reduce ICS dose by 25 to 50% every 2 to 3 months—consider the practicality of dose adjustments with the inhaled formulation prescribed (see Inhaled corticosteroid–based inhalers available in Australia for asthma in adults and adolescents for formulation details of inhalers).
- For a patient taking a low-dose ICS+LABA combination, step down to ICS monotherapy.
- For a patient taking regular budesonide+formoterol, step down to as-required budesonide+formoterol—this is associated with fewer exacerbations and better asthma control than using as-required SABA alone.
Stopping ICS preventer therapy in adults with asthma is associated with a significant risk of an asthma exacerbation. However, for patients who remain well controlled on minimum therapy (eg low-dose ICS), a closely monitored withdrawal of therapy can be trialled. Consider the strength of evidence for the original asthma diagnosis (eg variable airflow obstruction demonstrated on spirometry, compared with a symptom-based diagnosis). In two studies of patients diagnosed with asthma, one-third of patients had no evidence of variable airflow obstruction up to 12 months after withdrawing ICS therapy, even with bronchial provocation challenge12; this was more likely if spirometry had not been performed at the time of diagnosis. See Asthma diagnosis for information about how to correctly diagnose asthma in adults, adolescents and children older than 6 years.
If considering withdrawal of preventer therapy, discuss the risks with the patient and ensure they still have ready access to reliever therapy (either SABA or low-dose budesonide+formoterol). Following any step down in therapy, advise patients to step therapy back up asthma control deteriorates—this should be documented on their written asthma action plan.