Asthma - Stepping up and Stepping down Treatment

 Asthma step up – ‘Think TTT’

Before stepping up treatment ensure you check:

  • Therapy compliance
  • Technique with inhalers
  • Trigger factors

After stepping-up review patient in 8 weeks

Step up one drug / dosage at a time
Check equivalent steroid doses if changing drug or device

Asthma step down – review asthma control

Review symptom control over past 8-12 weeks with patient:

  • Use the Asthma Control Test or the Asthma Control Questionnaire.

Complete control of asthma is defined as:
NO – daytime symptoms
NO – night-time awakening due to asthma
NO – need for rescue medication
NO – exacerbations
NO – Limitation on activity including exercise
NORMAL – lung function assessed as FEV1 and/or PEF>80% predicted or best
With minimal side effects.

Complete control (or near complete control) needs to be achieved for 8-12 weeks before stepping down.

Stepping down before 8-12 weeks of control can lead to exacerbation

Asthma step down process

Step down will most commonly consist of a reduction in inhaled corticosteroid (ICS) dosage or stopping of long-acting beta-agonist (LABA).

 Inhaled corticosteroid reduction:

  • Reduce ICS dose by 25-50% each time

For combination inhalers use the next lowest strength of inhaler (do not reduce the number of doses as this reduces the LABA dosage also), if this is not possible, change to separate ICS and LABA inhalers

See LABA / ICS combination step down guide (adults)

LABA withdrawal:

  • Change to single agent ICS inhaler; ensure ICS dosage is equivalent

Review 12 weeks after stepping down:

  • Step patient up again if symptomatic during this period

For more information on use of inhaled corticosteroids in adults see Guidance for Healthcare Professionals

  • First Line Drugs
  • Second Line Drugs
  • Specialist Initiated Drugs with Shared Care Guidelines
  • Specialist Only Drugs
  • Mixed Status