The American College of Allergy, Asthma, and
Immunology (ACAAI) has published a new guideline “Asthma Controller Step Down
Yardstick” to help physicians decide when and how to step down asthma
controller therapy according to guideline-defined control levels after the
asthma symptoms improve and asthma is stable. The guideline outlines both
reasons for, and reasons not to consider stepping down treatment, which should
be “individualized according to the patient's current treatment, risk factors,
values, and preferences”.
As per the guideline, stepping down treatment
should be considered to:
·
Re-assess a current diagnosis of asthma.
·
Decrease the potential adverse effects of asthma
medications.
·
Address patient and family preferences about taking
medications.
·
Reduce the burden of treatment (e.g., time to take
medications, remembering to take medications, having to take medications at
work or school).
·
Reduce treatment costs.
·
Simplify therapy and enhance adherence with
treatment.
Consider not stepping down treatment when:
·
Reducing asthma medication may increase risk of
asthma exacerbation or loss of control.
·
It is unclear whether the patient is using asthma
medications as indicated.
·
A seasonal maintenance of therapy is needed (e.g.,
during the allergy season or viral season).
Stepping down from Step
2 treatment (ICS)
·
Patients who are likely to adhere to daily ICS
treatment: Once-daily low-dose ICS monotherapy or once-daily low-dose
ICS/long-acting beta-antagonist (LABA)
·
Patients who prefer an alternative to daily
treatment or who may not adhere to daily treatment: Anti-inflammatory/reliever
therapy with a combination ICS + fast-acting short-acting beta antagonist
(SABA) or the LABA formoterol
·
Patients who prefer an oral medication or who have
difficulty using an inhaler: Leukotriene modifier daily + SABA reliever
(as-needed)
Stepping Down From Step
3 Treatment
For patients using an
ICS/LABA combination
·
Decreasing the ICS dose by changing the number of
puffs or frequency of dosing
·
Switching to a combination product with a lower ICS
dose
·
Discontinuing the LABA while maintaining (and
potentially tapering over time) the ICS dose
For patients using only
an ICS
·
Decreasing the dose of ICS
·
Stepping down to a low-dose ICS/LABA
·
Using low-dose budesonide/formoterol as
maintenance and reliever medication (not FDA approved)
·
Patients with allergic asthma: Immunotherapy
to further reduce ICS dose
Stepping Down From Step
4 Treatment
·
Consider step down only after a careful review of
the patient's history confirms a minimum of 6 months of asthma control and no
exacerbations during the previous year.
·
For patients on ICS/LABA, reduce the dose of ICS
while maintaining LABA.
·
Patients on tiotropium with ICS: Lower the
dose of ICS while maintaining and possibly eventually discontinuing tiotropium
if control is maintained.
·
Patients using tiotropium + ICS/LABA: Stop
tiotropium while maintaining the ICS/LABA; wait at least 3 months between
titration steps to ensure control is established.
Stepping Down From Step
5 Treatment
·
Objectively evaluating oral corticosteroids (OCS)
and controller therapy use to determine adherence
·
Objectively evaluating responsiveness to a minimum
3-month trial of high-dose ICS/LABA under direct supervision
·
Initiating trial treatment with an appropriate
biologic agent for a minimum of 4 to 6 months; assess asthma control and
attempt to taper OCS over 2 to 4 months
The guideline is published online Dec. 12, 2018 in
the Annals of Allergy, Asthma and Immunology
(Source: Medscape, EurekAlert)
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical
Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA
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