Stepping Down Asthma Treatment: How and When
Stepping Down Asthma Treatment: How and When
Purpose of review Guidelines suggest that asthma medication should be reduced once asthma control is sustained. Moderatedose inhaled corticosteroids (ICS) can typically be reduced, but questions remain about the lowest effective ICS dose and the role of non-ICS controllers in treatment reduction. Long-acting beta agonist (LABA) safety concerns have created controversy about how to step down patients on ICS/LABA therapy. This review will focus on the current status of these issues.
Recent findings Intermittent ICS treatment, often in fixed combination with short-acting beta agonist, is an emerging strategy for control of mild asthma. Addition of leukotriene modifiers, LABAs, and omalizumab to ICS can allow for reduced ICS dosing. Doses of ICS that control symptoms may be inadequate to control exacerbations. Reducing ICS dose before discontinuing LABAs may be the more effective approach for patients on combination therapy.
Summary Use of non-ICS controllers allows for ICS dose reduction with superior outcomes. Tapering of ICS prior to LABA discontinuation may be the favored approach for patients on ICS/LABA therapy, but an understanding of long-term outcomes and further safety data are required. The lowest ICS dose that adequately controls both asthma impairment and risk remains to be determined.
Asthma guidelines focus on achieving and maintaining asthma control and balancing the risk of medications with control of disease. They suggest that once symptoms are controlled for at least 3 months, therapy can be reduced to the lowest dose that maintains control. Despite these recommendations, questions remain about when and how to reduce asthma therapy. Benefits of inhaled corticosteroids (ICS) are well established, and adverse effects are uncommon at low and moderate doses. However, concerns about adverse effects remain, particularly with sustained high doses, and include osteoporosis, adrenal axis suppression, cataracts, hoarseness, dysphonia, oral candidiasis, and dermal thinning and bruising. Recent links of ICS to diabetes and pneumonia are cause for concern and require further investigation. HIV patients on antiretroviral therapy and ICS can have significant systemic absorption and adverse effects. Ongoing concerns in children include continued evidence of reduced growth velocity without an ultimate impact on adult height. Apart from concerns about adverse effects of higher doses of ICS, safety concerns about long-acting beta agonists (LABAs) create questions about the optimal way to reduce combination ICS/LABA therapy. Carefully monitored therapy reduction trials can clarify disease severity and reduce over-treatment. This review will discuss the current state of knowledge of how one should reduce therapy when asthma control is sustained.
Abstract and Introduction
Abstract
Purpose of review Guidelines suggest that asthma medication should be reduced once asthma control is sustained. Moderatedose inhaled corticosteroids (ICS) can typically be reduced, but questions remain about the lowest effective ICS dose and the role of non-ICS controllers in treatment reduction. Long-acting beta agonist (LABA) safety concerns have created controversy about how to step down patients on ICS/LABA therapy. This review will focus on the current status of these issues.
Recent findings Intermittent ICS treatment, often in fixed combination with short-acting beta agonist, is an emerging strategy for control of mild asthma. Addition of leukotriene modifiers, LABAs, and omalizumab to ICS can allow for reduced ICS dosing. Doses of ICS that control symptoms may be inadequate to control exacerbations. Reducing ICS dose before discontinuing LABAs may be the more effective approach for patients on combination therapy.
Summary Use of non-ICS controllers allows for ICS dose reduction with superior outcomes. Tapering of ICS prior to LABA discontinuation may be the favored approach for patients on ICS/LABA therapy, but an understanding of long-term outcomes and further safety data are required. The lowest ICS dose that adequately controls both asthma impairment and risk remains to be determined.
Introduction
Asthma guidelines focus on achieving and maintaining asthma control and balancing the risk of medications with control of disease. They suggest that once symptoms are controlled for at least 3 months, therapy can be reduced to the lowest dose that maintains control. Despite these recommendations, questions remain about when and how to reduce asthma therapy. Benefits of inhaled corticosteroids (ICS) are well established, and adverse effects are uncommon at low and moderate doses. However, concerns about adverse effects remain, particularly with sustained high doses, and include osteoporosis, adrenal axis suppression, cataracts, hoarseness, dysphonia, oral candidiasis, and dermal thinning and bruising. Recent links of ICS to diabetes and pneumonia are cause for concern and require further investigation. HIV patients on antiretroviral therapy and ICS can have significant systemic absorption and adverse effects. Ongoing concerns in children include continued evidence of reduced growth velocity without an ultimate impact on adult height. Apart from concerns about adverse effects of higher doses of ICS, safety concerns about long-acting beta agonists (LABAs) create questions about the optimal way to reduce combination ICS/LABA therapy. Carefully monitored therapy reduction trials can clarify disease severity and reduce over-treatment. This review will discuss the current state of knowledge of how one should reduce therapy when asthma control is sustained.