Stepping down for mild asthma and disadvantages of the ‘as‐needed’ strategy—Perspectives from a developing country

Abstract

Stepping down for mild asthma and disadvantages of the 'asneeded' strategy-Perspectives from a developing countryStepping down for well-controlled asthma is crucial to achieve the lowest effective inhaled corticosteroid (ICS) dose. However, recommendations for stepping down are still ambiguous, particularly regarding the step-down strategy in patients with well-controlled asthma treated with once-daily low-dose ICS/long-acting beta 2 -agonist (LABA) combination. The 2021 Global Initiative for Asthma (GINA) guideline recommended 'as-needed' low-dose ICS-formoterol (ICS-FOR) as a therapeutic option for Step 2 asthmatics among adolescents and adults. 1 Whether patients whose asthma is well controlled with once-daily low-dose ICS/LABA could be stepped down to ICS-FOR as needed is still an open question because: (1) as-needed therapy is inconsistent with the previous preventive purpose of GINA guidelines and ( 2) it has the potential risk of poor outcomes if not enough ICS are taken.Based on the higher risk of mortality when using shortacting beta 2 -agonist alone and the strong evidence for efficacy of as-needed ICS-FOR strategy in the past decade, GINA guidelines recommended the therapeutic option of ICS-FOR as needed for Step 1 and Step 2. 1 This strategy resulted in reducing the risk of severe exacerbation but with limited evidence of improvement in both symptom control and lung function compared with daily low-dose ICS treatment. 2 Despite the unquestionable strength of evidence provided by randomized controlled trials on the efficiency of the as-needed strategy, we are not absolutely certain about the effectiveness of this strategy when applied to real-world clinical practice in low-and middle-income countries, for these reasons: