Stepping down asthma therapy in children

If asthma has been stable and well controlled for at least 3 months, gradually step down therapy to the minimum regimen that maintains good asthma symptom control—see Classification of asthma symptom control in children for definitions. Using the minimum regimen can reduce the risk of treatment-related adverse effects. Review symptom control and perform spirometry (if appropriate) 4 to 6 weeks after adjusting therapy.

Avoid stepping down therapy at the start of the preschool or school year, or at the start of the peak asthma season in children with seasonal variation.

In a child whose asthma has been well controlled for at least 3 months, consider stepping down therapy with the following approach:

For children taking high-dose ICS, gradually reduce to lower-dose ICS.
For children taking low-dose ICS plus montelukast, switch to ICS monotherapy.
For children taking an ICS plus a long-acting beta₂ agonist (LABA), reduce the dose of ICS; if low-dose ICS+LABA is already being used, switch to ICS monotherapy.

If control remains good on low-dose ICS monotherapy or montelukast monotherapy, consider stopping preventer therapy and using only as-required short-acting beta₂ agonist (SABA). Stopping ICS altogether is associated with a significant risk of an asthma exacerbation. If considering withdrawal of preventer therapy, discuss the risks with the patient and their parents or carers and ensure they still have ready access to reliever therapy.

Note: Advise the child and their parents or carers to step up therapy if asthma control deteriorates after stepping down therapy.