• 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% to 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.

In depth

• Review a person with stable asthma at least once a year. More frequent follow up may be needed after the initial diagnosis, when there is a change to medication, or in people with severe asthma or recurrent exacerbations.
• Review asthma control:
• Ask about symptoms, during the day; difficulty sleeping; and the impact of asthma on such activities as exercise, work, or school in the past week or month.
• Assess lung function using spirometry or Peak Expiratory Flow.
• Ask about past exacerbations and their frequency, and whether oral corticosteroids or hospital admission was needed.
• Ask about possible trigger factors such as exercise, work, and allergens.
• Ask about other conditions, that are known to co-exist with asthma and aggravate symptoms e.g. allergic rhinitis, sleep apnoea, and gastro-oesophageal reflux disease.
• Look for signs of complications which may necessitate referral to a specialist.
• Review asthma medication:
• Ask about the use of reliever medication, any benefits seen with changes in medication, and compliance with treatment.
• Assess inhaler technique and check peak expiratory flow rate to compare with the previously recorded value.
• Review smoking habit. Encourage people with asthma or parents of children with asthma to stop smoking.
• Review self-management education and make any necessary changes to written action plans.

In depth

• Advise overweight people that a healthy diet and regular exercise will help with weight reduction and improve asthma control:
• Advise people (if possible) to take 30 minutes of exercise to increase their heart rate at least five times weekly. For more information on weight loss, see the CKS topic on Obesity.

In depth

• Advise smokers with asthma to stop smoking and provide them with the appropriate help. For more information, see the CKS topic on Smoking cessation.
• Advise people with asthma to, as far as possible, avoid exposure to tobacco smoke. For parents who smoke and have a child with asthma, this means either stopping smoking (the best option), or not smoking in the same room as the child (or, preferably, not smoking in the house).

In depth

• Advise an influenza and a pneumococcal vaccination if asthma is severe and requires hospital admission or frequent use of corticosteroids.
• For more information, see the CKS topics on:
• Immunizations - seasonal influenza.
• Immunizations - pneumococcal.

In depth

• Advise to report symptoms of conditions that could worsen asthma, such as rhinitis, sinusitis, gastro-oesophageal reflux disease, and sleep apnoea.

In depth

• Advise to avoid (if possible) known trigger factors, especially at times when asthma is poorly controlled.
• Advise all adults to report promptly any worsening asthma control during work.

In depth

Prescription details are provided only for combined inhalers. In many people it may be more appropriate to step down treatment. See the Clinical summary recommendation for details of how to step down treatment.