Step-down therapy in asthma: A focus on treatment options for patients receiving inhaled corticosteroids and long-acting beta-agonist combination therapy

The management of asthma requires continual reassessment of disease activity and modification of treatment approaches based on the level of asthma control. Among patients receiving combination therapy with inhaled corticosteroids and long-acting beta-agonists (LABAs), asthma guidelines and guidance from the Food and Drug Administration recommend consideration of step-down therapy when asthma control has been achieved. This report reviews the evidence base surrounding medical decision making for patients receiving combination therapy. Several studies have examined the effects of step-down therapy in patients receiving combination therapy. Interpretation of these studies is complicated by lack of confirmation of necessity of combination therapy, varying definitions of asthma control before step-down along with variable durations of asthma control before step-down therapy. Overall, most studies indicate that the discontinuation of LABA after a brief period of asthma control is generally followed by loss of asthma control. The consideration of step-down in asthma medications is an essential component of asthma care over time. However, there are inadequate data at the present time to provide firm guidance as to the optimal step-down approach. Therefore, clinicians will need to balance the benefits and risks associated with these therapies on an individual patient basis as they consider which patients should undergo step-down and which approach would be most appropriate.