Asthma Step Therapy

July 6, 2017


As a pharmacist I am concerned with the number of persistent asthmatic patients who being treated solely with a short acting bronchodilator such as albuterol. While this may be appropriate for many mild intermittent asthmatic patients, those with a persistent form of the disease achieve better control of their disease with longer acting drugs especially drugs with anti-inflammatory action such as inhaled corticosteroids. We need to get rid once and for all of the misguided mindset: no wheeze = no disease that still has many followers.


Asthma therapy can be initiated as either step up to gradually gain control or step down to rapidly gain control. Although I have not seen any scientific studies that directly compared the two techniques, step down therapy is the method that I prefer for a variety of reasons. The primary reason I like the step down plan is that it can result in control being gained sooner. Another benefit is that it answers the question of whether a higher dose might provide more benefit yet at the same time still allowing the patient to ultimately end up on the lowest dose necessary for sustained control.

In step down therapy, treatment is initiated at a level one step higher than the presenting symptoms and tests indicate. For example a patient who is symptomatic twice per week but usually less than once per day and has nighttime symptoms about twice per month would typically be staged as mild persistent. With step down therapy the patient would begin therapy at the next highest level (moderate persistent). If control is achieved after an initial period of a month or so then therapy might gradually be reduced to a step lower (mild persistent). Due to the many variables involved such as unknown triggers and lack of certainty as to how rapidly the patient may deteriorate, many physicians prefer to stay at the higher level for a few months to be certain that long term control has actually been achieved. Control can be based on such parameters as: acceptable peak flow readings and variations, limited need for rescue inhaler use and elimination of nighttime symptoms. Certainly a patient that is not under apparent control after a month or so needs further evaluation with possible plan changes or additional testing to verify the diagnosis.

If the decision is made to begin a step down process, it is important to do so very gradually so as not to lose the control already achieved. If using an inhaled corticosteroid it is often decreased at a rate of 25% every few months to the lowest dose needed to maintain control. If the patient ends up on the lowest dose of a given product the physician may consider changing to a lower potency inhaled corticosteroid to see if further reduction is possible. It should be noted that if the patient is truly a persistent type asthmatic and not just a mild intermittent with an exacerbation, then it is unlikely that stopping the inhaled corticosteroid is a good idea. Most persistent patients will continue to benefit when the anti-inflammatory corticosteroid is continued at a low dose. If additional controller drugs such as salmeterol were being used a decision to stop them might make more sense. I know of at least one study that seems to indicate that patients on salmeterol might have a reduced response to albuterol when it is needed for rescue use. Therefore a well controlled persistent asthmatic with minimal need for medication might be most appropriately treated with only a low dose inhaled corticosteroid supplemented occasionally with a rapid acting beta agonist such as albuterol.


Step down therapy for asthma is a logical, results based, technique that provides rapid control of asthma yet allows progressive reduction of medications to the lowest level necessary to maintain long term control.

Although as current and accurate as possible, the information contained and opinions expressed in this article or provided to you by the author in email or any other manner, may not relate to your particular medical condition and are not intended to be used as the direct basis for diagnosis or treatment of any specific medical condition. Always refer to your healthcare provider before making any changes in your treatment plan.

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