Assessing patient response to Step 4 therapy

Assess symptom control 4 to 8 weeks after starting Step 4 therapy. See Assessment of asthma control in adults and adolescents for classification of good, partial and poor control.

If the patient’s symptoms are well controlled with Step 4 therapy, continue treatment and review again after 3 months. Attempt to step down therapy if control remains good. Few patients require long-term treatment with Step 4 therapy.

If the patient has partial or poor control on Step 4 therapy, review adherence and inhaler technique, and check equipment (drug device, spacer) for breakage or blockage. Before escalating to Step 5 therapy, also assess for comorbidities (eg rhinitis) that could be reducing asthma control, and ensure exposure to triggers is minimised.

Note: Every asthma assessment should include a review of treatment adherence and inhaler technique.

If the patient is using a therapy other than ICS+LABA (eg montelukast, ICS monotherapy) and has partial or poor control, switch therapy to ICS+LABA rather than escalating to Step 5 therapy, if possible.

All patients who are uncontrolled on Step 4 therapy should be referred to a respiratory physician, particularly if the patient has shown minimal response to treatment or if the diagnosis is in doubt.