Stepping down the dose of inhaled corticosteroids for adults with asthma

Crossingham, Iain; Evans, David; Halcovitch, Nathan R.; Marsden, Paul

doi:10.1002/14651858.cd011802.pub2

Cited by 13 publications

(9 citation statements)

References 58 publications

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“…Rank et al reported that withdrawing low‐dose ICS was associated with a higher risk of exacerbations, which occurred in 38% of those patients over a mean period of 6 months. In contrast, Hagan et al suggested that reducing ICS to a lower dose did not increase the risk of asthma exacerbations while in a recent article, Crossingham et al concluded that the body of evidence was insufficient to draw conclusions about the risks and benefits of stepping‐down ICS. In these studies, the prevalence of exacerbations was 21% and 18%, respectively, over a mean follow‐up of 5‐6 months in patients whose ICSs were reduced.…”

Section: Discussionmentioning

confidence: 97%

Step‐down of inhaled corticosteroids in non‐eosinophilic asthma: A prospective trial in real life

Demarche

Schleich

Henket

et al. 2018

Clin Experimental Allergy

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Section: Discussionmentioning

confidence: 97%

Step‐down of inhaled corticosteroids in non‐eosinophilic asthma: A prospective trial in real life

Demarche

Schleich

Henket

et al. 2018

Clin Experimental Allergy

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“…Two Cochrane reviews found insufficient trial evidence regarding step down of ICS or long-acting beta agonists (LABA). 16,17 Participants in our study used a variety of approaches to step down, reducing both ICS and LABA or just ICS; with even less concord for patients with an additional asthma therapy. Moreover, there was no consensus as to how to identify suitable patients.…”

Section: Discussionmentioning

confidence: 99%

<p>Qualitative Study of Practices and Challenges of Stepping Down Asthma Medication in Primary Care Across the UK</p>

Bloom¹,

Ramsey²,

Alter³

et al. 2020

JAA

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Background: Guidelines recommend that asthma treatment should be stepped down to the minimally effective dose that achieves symptom control to prevent medication side effects and reduce unnecessary costs. Little is known about the practice of stepping down and the challenges in primary care, where most asthma patients are managed. Objective: To explore views, experiences, barriers and ideas, of doctors, nurses and pharmacists working in primary care, related to step down of asthma medication. Methods: Primary care practitioners from across the UK participated in a survey and/or semi-structured interview. Questions explored four main areas: how asthma medication is reviewed, views on asthma guidelines, perceived barriers faced by healthcare workers and facilitators of stepping down. Qualitative content analysis enabled data coding of interview transcripts to identify major themes. Results: A total of 274 participants responded to the survey, 29 participated in an interview (12 doctors, 9 nurses, and 8 pharmacists), working in GP practices from across the UK. Nearly half of the survey participants infrequently step down asthma medication (doc-tors=42.7%, nurses=46.3%). Four major themes related to barriers to stepping down were (i) lack of awareness of the need to step down, (ii) inertia to step down, driven by low confidence in ability, fear of consequences, and concern for who is responsible for stepping down, (iii) self-efficacy of ability to step down, influenced by lack of clear, applied guidance and limited training, and (iv) feasibility of step down, driven by a lack of systematic acceptance of stepping down and time. Strategies proposed to reduce overtreatment included education and training, improved gathering of evidence and guidance, and integrating step down into routine asthma care. Conclusion: Failure to implement this guideline recommendation into everyday asthma management is influenced by several contributing factors. Future directions should include addressing evidence gaps, implementing clear and practical guidance, integration of stepdown assessment into the asthma review, and education of professionals and patients.

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“…65 Comparing those who stepped down with controls, no significant differences were found for several outcomes including needing oral corticosteroid (odds ratio 1.31, 0.82 to 2.08), hospital admission (4.06, 0.45 to 36.9), or all cause serious adverse events (0.60, 0.11 to 3.33). 31 The odds ratio of 4 for hospital admission may be clinically relevant; however, owing to the limited number of events and high level of imprecision, this result should be interpreted with caution.…”

Section: Substitution Of Leukotriene Receptor Antagonists For Inhaledmentioning

confidence: 95%

Why and how to step down chronic asthma drugs

Gionfriddo

Hagan

Rank

2017

BMJ

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Asthma is a common chronic airways disease. The goal of asthma management is to control symptoms while minimizing the side effects of treatment. Following a period of stable asthma, clinicians should consider stepping down treatment. This approach is recommended by current guidelines. Step-down has been studied for several types of asthma drug regimens, and certain approaches may have lower risk than others. Systematic reviews of multiple trials support the following specific step-down approaches: optimizing inhaled corticosteroid dosing when stepping down oral corticosteroid, reducing inhaled corticosteroid from a higher dose, lowering inhaled corticosteroid-long acting bronchodilator (ICS-LABA) dose while adding ICS-LABA on-demand, adding leukotriene receptor antagonist (LTRA) while lowering inhaled corticosteroid dose, and using allergen immunotherapy when reducing inhaled corticosteroid from a higher dose. Systematic reviews of multiple trials support an increased risk of asthma exacerbation for patients who completely stop taking inhaled corticosteroid or long acting bronchodilator. Strategies to implement step-down in practice include the use of risk prediction as well as tools to support shared decision making and communication about risk between clinicians and patients.

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Stepping down the dose of inhaled corticosteroids for adults with asthma

Cited by 13 publications

References 58 publications

Step‐down of inhaled corticosteroids in non‐eosinophilic asthma: A prospective trial in real life

Step‐down of inhaled corticosteroids in non‐eosinophilic asthma: A prospective trial in real life

<p>Qualitative Study of Practices and Challenges of Stepping Down Asthma Medication in Primary Care Across the UK</p>

Why and how to step down chronic asthma drugs

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