Stepping down inhaled corticosteroids in asthma: randomised controlled trial

Abstract

Objectives To determine whether the dose of inhaled corticosteroids can be stepped down in patients with chronic stable asthma while maintaining control. Design One year, randomised controlled, double blind, parallel group trial. Setting General practices throughout western and central Scotland. Participants 259 adult patients with asthma receiving regular treatment with inhaled corticosteroids at high dose (mean dose 1430 g beclomethasone dipropionate). Interventions Participants were allocated to receive either no alteration to their dose of inhaled corticosteroid (control) or a 50% reduction in their dose if they met criteria for stable asthma (stepdown). Main outcome measuresComparison of asthma exacerbation rates, asthma related visits to general practice and hospital, health status measures, and corticosteroid dosage between the two groups. Results The proportions of subjects with asthma exacerbations were not significantly different (stepdown 31%, control 26%, P=0.354). Similarly, the numbers of visits to general practice or hospital and the disease specific and generic measures of health status over the one year period were not significantly different. On average the stepdown group received 348 g (95% confidence interval 202 g to 494 g) of beclomethasone dipropionate less per day than the controls (a difference of 25%), with no difference in the annual dose of oral corticosteroids between the two treatment regimens. Conclusions By adopting a stepdown approach to the use of inhaled steroids at high doses in asthma a reduction in the dose can be achieved without compromising asthma control.

Global strategy for asthma management and prevention: GINA executive summary

“…1) When inhaled glucocorticosteroids alone are being used in medium-to-high doses, a 50% reduction in dose should be attempted at 3-month intervals (Evidence B) [151,308,309].…”

Overtreatment with inhaled corticosteroids and diagnostic problems in primary care patients, an exploratory study

“…Nor could pulmonologists exclude the 'benefit of the doubt' when diagnosing asthma in patients using ICS who had a normal lung function and only minor complaints. For at least 30% of these patients, it was possible to decrease their dose of ICS without problems, which could indicate either achieved asthma control 17 or-in some patients-misdiagnosed 'asthma'. These facts suggest a higher number of patients using ICS unnecessarily and an underestimation of the problem we examined.…”

A Review on the Safety and Efficacy of Inhaled Corticosteroids in the Management of Asthma

“…Analysis of randomized controlled trial (RCT) studies that examined step-down of asthma medications suggested that each of the methods of stepping down from ICS to reduced ICS dose [58][59][60][61], scheduled ICS to on demand ICS [57,62], or ICS to leukotriene receptor antagonist (LTRA) [63] may be safe options for many patients with stable asthma. However, each of these step-down strategies likely confers an increased risk of having an exacerbation or loss of asthma control compared with continuing the current asthma regimen.…”