PART B. MEDICATIONS AND STRATEGIES FOR SYMPTOM CONTROL AND RISK REDUCTION KEY POINTS
REVIEWING RESPONSE AND ADJUSTING TREATMENT
How often should asthma be reviewed?
Patients with asthma should be reviewed regularly to monitor their symptom control, risk factors and occurrence of exacerbations, as well as to document the response to any treatment changes. For most controller medications, improvement begins within days of initiating treatment, but the full benefit may only be evident after 3–4 months.245 In severe and chronically under-treated disease, it may take longer.246
All health care providers should be encouraged to assess asthma control, adherence and inhaler technique at every visit, not just when the patient presents because of their asthma.247 The frequency of visits depends upon the patient’s initial level of control, their response to treatment, and their level of engagement in self-management. Ideally, patients should be seen 1–3 months after starting treatment and every 3–12 months thereafter. After an exacerbation, a review visit within 1 week should be scheduled248 (Evidence D).
Stepping up asthma treatment
Asthma is a variable condition, and periodic treatment adjustments by the clinician and/or the patient may be needed.249
• Sustained step up (for at least 2–3 months): although at a group level most benefit from ICS is obtained at low dose, individual ICS responsiveness varies, and some patients whose asthma is uncontrolled on low dose ICS-LABA despite good adherence and correct technique may benefit from increasing the maintenance dose to medium. A step up in treatment may be recommended (Box 3-5, p31) if the symptoms are confirmed to be due to asthma; inhaler technique and adherence are satisfactory; and modifiable risk factors such as smoking have been addressed (Box 3-8, p38). Any step-up should be regarded as a therapeutic trial, and the response reviewed after 2–3 months. If there is no response, treatment should be reduced to the previous level, and alternative treatment options or referral considered.
• Short-term step up (for 1–2 weeks): an occasional short-term increase in maintenance ICS dose for 1–2 weeks may be necessary; for example, during viral infections or seasonal allergen exposure. This may be initiated by the patient according to their written asthma action plan (Box 4-2, p61), or by the health care provider.
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• Day-to-day adjustment: for patients prescribed combination budesonide-formoterol or beclometasone-formoterol as maintenance and reliever treatment, the patient adjusts the number of as-needed doses of ICS-formoterol from day to day according to their symptoms, while continuing the maintenance dosage.
Stepping down treatment when asthma is well controlled
Once good asthma control has been achieved and maintained for 3 months and lung function has reached a plateau, treatment can often be successfully reduced, without loss of asthma control. The aims of stepping down are:
• To find the patient’s minimum effective treatment, i.e. to maintain good control of symptoms and exacerbations, and to minimize the costs of treatment and potential for side-effects
• To encourage the patient to continue controller treatment. Patients often experiment with intermittent treatment through concern about the risks or costs of daily treatment,250 but this leaves them exposed to the risks of SABA-only treatment. For patients prescribed maintenance ICS-containing treatment with SABA reliever, it may be helpful to inform them that lower doses can be achieved if controller treatment is taken every day. For patients whose asthma is well-controlled on low dose ICS or LTRA, controller treatment can be continued at a very low average daily ICS dose by prescription of as-needed ICS-formoterol.174,178
Before stepping down
The approach to stepping down will differ from patient to patient depending on their current treatment, risk factors and preferences. There are few experimental data on the optimal timing, sequence and magnitude of treatment reductions in asthma.
Predictors of loss of control during dose reduction include airway hyperresponsiveness and sputum eosinophilia,251 but these tests are not readily available in primary care. In one study, a history of exacerbations in the previous 12 months was associated with greater risk of exacerbation after step-down.252
Any step-down of asthma treatment should be considered as a therapeutic trial, with the response evaluated in terms of both symptom control and exacerbation frequency. Prior to stepping down treatment, the patient should be provided with a written asthma action plan and instructions for how and when to resume their previous treatment if their symptoms worsen.
How to step down treatment
Decisions about treatment step-down should be made on an individual patient level. In one study of patients with well-controlled asthma on medium dose ICS-LABA, reducing the ICS dose and removing the LABA had similar effects on a composite treatment failure outcome. However, stopping LABA was associated with lower lung function and more hospitalizations; and decreasing the ICS dose was inferior to maintaining a stable dose of ICS-LABA.253 If treatment is stepped down too far or too quickly, exacerbation risk may increase even if symptoms remain reasonably controlled254 (Evidence B). Complete cessation of ICS is associated with a significant risk of exacerbations255 (Evidence A).
Step-down strategies for different controller treatments are summarized in Box 3-7, p.56; these are based on current evidence, but more research is needed. Only a small number of step-down studies have been performed in children.
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Box 3-7. Options for stepping down treatment once asthma is well controlled General principles of stepping down asthma treatment
• Consider stepping down when asthma symptoms have been well controlled and lung function has been stable for 3 or more months (Evidence D). If the patient has risk factors for exacerbations (Box 2-2, p17), for example a history of exacerbations in the past year,252 or persistent airflow limitation, do not step down without close supervision.
• Choose an appropriate time (no respiratory infection, patient not travelling, not pregnant).
• Approach each step as a therapeutic trial. Engage the patient in the process; document their asthma status (symptom control, lung function and risk factors, Box 2-2); provide clear instructions; provide a written asthma action plan (Box 4-2, p61) and ensure the patient has sufficient medication to resume their previous dose if necessary; monitor symptoms and/or PEF; and schedule a follow-up visit (Evidence D).
• Stepping down ICS doses by 25-50% at 3 month intervals is feasible and safe for most patients256 (Evidence A).
Current Current medication
step and dose Options for stepping down Evidence
Step 5 High dose ICS-LABA plus oral corticosteroids (OCS)
• Continue high dose ICS-LABA and reduce OCS dose
• Use sputum-guided approach to reducing OCS
• Alternate-day OCS treatment
Step 4 Moderate to high dose ICS-LABA maintenance treatment
• Continue combination ICS-LABA with 50% reduction in ICS component, by using available formulations
• Discontinuing LABA may lead to deterioration257
B A Medium dose
ICS-formoterol* as maintenance and reliever
• Reduce maintenance ICS-formoterol* to low dose, and continue as-needed low dose ICS-formoterol* reliever
D
High dose ICS plus second controller
• Reduce ICS dose by 50% and continue second controller256 B
Step 3 Low dose ICS-LABA maintenance
• Reduce ICS-LABA to once daily
• Discontinuing LABA may lead to deterioration257
D A Low dose ICS-formoterol*
as maintenance and reliever
• Reduce maintenance ICS-formoterol* dose to once daily and continue as-needed low dose ICS-formoterol* reliever
C
Moderate- or high-dose ICS • Reduce ICS dose by 50%256 A
Step 2 Low dose ICS • Once-daily dosing (budesonide, ciclesonide, mometasone)258,259
• Switch to as-needed low dose ICS-formoterol174,178
• Adding LTRA may allow ICS dose to be stepped down260
• Insufficient evidence to support step-down to as-needed ICS with SABA261
A A B -
Low dose ICS or LTRA • Switch to as-needed low dose ICS formoterol174,178
• Complete cessation of ICS in adults and adolescents is not advised as the risk of exacerbations is increased with SABA-only treatment255
A A
BDP: beclometasone dipropionate; ICS: inhaled corticosteroids; LABA: long-acting beta2-agonist; LTRA: leukotriene receptor antagonist; OCS: oral corticosteroids.
*ICS-formoterol maintenance and reliever treatment can be prescribed with low dose budesonide-formoterol or BDP-formoterol.