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
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
See LABA / ICS Combination inhaler step down guide for more information
- First Line Drugs
- Second Line Drugs
- Specialist Initiated Drugs
- Specialist Only Drugs
- Mixed Status