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Asthma - Management
Children and adults with controlled symptoms on current treatment: How do I manage?

  • Do NOT step down treatment for people who have ongoing symptoms or need inhaled short-acting beta2-agonists, and those who have had a recent exacerbation.
  • If a person has controlled symptoms, consider the following approach to step-down treatment:
    • Make sure the person feels that their asthma is controlled and that they are willing to try step-down treatment.
    • Reduce the dose of inhaled corticosteroids slowly.
      • The usual protocol is to decrease the dose by 25–50% per 3-month visit. Explain the potential for worsening symptoms and the increased risk of an exacerbation.
      • Some children with milder asthma and a clear seasonal pattern to their symptoms may tolerate a more rapid dose reduction during their 'good' season.
    • Review the person on a regular basis; promote lifestyle advice, assess for worsening symptoms, and consider increasing medication if the person's asthma deteriorates.
  • If stepping down is not possible, and the person is stable on an inhaled corticosteroid and a long-acting beta2-agonist, consider prescribing a combination inhaler.
Clarification / Additional information
  • Discuss the reason for reducing medication (to minimize adverse effects), and always take the person's preference into consideration.
  • Update the person's written 'action plan' and reinforce how to recognize and manage an exacerbation.
  • Tailor the management to the individual, on the basis of their combination of drugs and the doses needed to achieve asthma control:
    • If a person is on a combination of inhaled corticosteroids (ICS) and add-on therapy, slowly reduce the ICS to the lowest dose possible; if asthma control is maintained consider stopping add-on therapy [GINA, 2006]. Some experts (although there is no clear evidence to do so) recommend discontinuing any regular use of a beta–agonist (short or long–acting) before reducing the inhaled corticosteroid dose below 400 micrograms daily.
    • Preventive ICS treatment may possibly be stopped if asthma remains controlled on the lowest possible dose and symptoms do not recur for one year [GINA, 2006].
Basis for recommendation
  • These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
    • The reduced need for medication once control is achieved is not fully understood. Possibilities include a reversal of long-term inflammation in the airways or spontaneous improvement as part of the cyclical natural history of asthma [GINA, 2006].
    • Few studies have investigated the most appropriate way of stepping down treatment. One study in adults with stable asthma who used at least 900 micrograms of inhaled corticosteroids daily showed that the dose could be halved every 3 months with no significant deterioration in symptoms [SIGN and BTS, 2009].

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