Inhaled corticosteroids are the key controllers in Asthma but the long term use is linked to some important side-effects.
Guidelines dictate that patients with mild asthma can be maintained on low dose ICS alone. In patients who are on moderate dose ICS and a LABA, while either dropping the LABA or reducing ICS dose is acceptable, I generally step down to an ICS monotherapy before reducing steroid dose further.
If asthma is well controlled I generally stop LABA and switch to escape SABA and continue with ICS maintenance. As a second step I try to reduce the dose of ICS
I am a non clinical scientist with a long standing interest in asthma. The BTS/SIGN asthma guideline; 2012 is a useful review of evidence base,
http://www.brit-thoracic.org.uk/Guidelines/Asthma-Guidelines.aspx
I suggest to read the editorial in the N Engl J Med 356;20 www.nejm.org may 17, 2007 and the paper Papi A, Canonica GW, Maestrelli P, et al. Rescue use of inhaled
beclomethasone and albuterol in a single inhaler for mild
asthma. N Engl J Med 2007;356:2040-52.
in this issue of the NEJM three different strategies for stepping down patients with mild persistent asthma are documented.
It depends on the the current treatment the patient is receiving. Never give LABA alone, so when on low ICS and LABA, stop LABA. When the patient is only on ICS, stop ICS and give SABA alone. When on medium or high dose ICS + LABA it depends on the patient. In patients with a history of atopy and frequent exacerbations I would prefer to stop LABA. Whereas in obese patients I would reduce ICS
discontinuation of the ICS in patients showing controlled asthma for e.g. 3 months is the option indicated in the guidelines leading to the minimum possible therapy (fast-acrting bronchodilator alone as needed) btu the evidence is D. However, there is increasing evidence supporting the intermittent as needed use of fixed combinations of ICS and rapid-acting bronchodilators (e.g. salbutamol or formoterol) which has several advantages over the single bronchodilaotr monotherapy. first of all asthma is an inflammatory disease and even if symptoms are infrequernt and lung function is normal, inflammation has to be addressed. Leaving a patient with rescue bronchodialtor only as antiasthmatic therapy is nowadays, not the best option in my opinion.
rescue use of fawst-acting bronchodilartor/ICS combination allows the patient to have a symptom-drtiven treatment and adjust the need in case of symptoms increase. The ICS in the combination can have a rapid effect on the flares of inflammation leading to symptoms increase and can contribute avoiding the acute worsening of the disease.
Moreover, a patient with as needed bronchiodilator alone therapy would need to be mnonitored frequently to check if the use is more than twice a week in order to consider a step-up in therapy.
to make a long story short I do not think stopping ICS is a good option.
A useful reading: Rescue treatment in asthma. More than as-needed bronchodilation. Papi A, Caramori G, Adcock IM, Barnes PJ.
Chest. 2009 Jun;135(6):1628-33.
Thank you all for responses.
Step-up and step-down strategy of medication, ICS or combination with LABA is the recomendation of the current guidelines.
Most patients achieve asthma control with ICS. Alternative are leucotriene modifiers, predominantly in patients with asthma and rhinitis.
In my view, mainly clinical activity, these patients are candidates for specific immunotherapy, when allergic etiology can be identified.
Also, I get great results, mainly in children. with use of leukotrienes.
Leokotrienes might be an option for very mild asthma not requiring ICS. In my opinion there is a very limited place for immunotherapy in allergic asthma.
We look for the lowest level of ICS, in order to maintain control once achieved. Even ICS every other day might be an alternative to further step - donwn medication. Some patiens do that in clinical practice. Compliance is difficult, with less/no symtoms.
Good point, dr. Sanchez-Machin. For children, leucotriene – modifiers are a good alternative to step-down the medication, including as monotherapy for mild allergic asthma. In particular cases, imunotherapy is guideline recommended.
I completely agree with Joachim Ficker, his recommendation is the best way, take care with discontinuation of ICS, taper them
Very interesting discussion. IN my experience over the past few years I found exhaled NO to be the best indicator and marker if I can reduce or even stopped ICS. I have used it in hundreds of childen and found i very rewarding and assuring to parents. No other tests can indicate this so easily
This only pertains to patients who are well controlled on current therapies and meet NAEPP criteria for being well controlled. First discontinue LABAs and switch to SABAs + ICS on as needed basis while continuing regular ics. If still controlled, then ICS may be tapered and eventually discontinued while continuing PRN ICS+Saba. If patient becomes uncontrolled then one can always escalate. One can use symptoms, NO, or sputum eosinophils to gauge underlying inflammation and whether or not one can taper or need to escalate.
The excess of inhaled corticosteroid is a frequent problem in managing asthma (local effects, long-term accumulation and respiratory infection). As Dr Nicolini proposes, the association B2+IGC has demonstrated highly effectively and allows the control of asthma with fewer IGC's dose. To reduce the dose of ICG an associate B2 works well. Formoterol in association has the advantage of adapting dose depending on the symptoms and inflammatory load, i.e., therapy Smart.
Montelukast has a small and limited efficacy (I only consider it in children, as alternative to the IGC, in allergic and non allergic asthma). And immunotherapy, not only is a controversial treatment of asthma, but a serious mistake in a situation of step-down.
Ho trovato la ciclesonide in monosomministrazione
un ottimo rimedio nell'asma lieve
d'accordo con l'utilizzo degli antileucotrieni nei bambini
I agree with the comments of Israel Amirav. Attached you can see a poster I will present next may at the ATS
Thank you Israel and Alejandro.
Probably the best tool in children with asthma, indeed.
In stepping down from low-dose ICS, a strategy to consider is using ICS each time a SABA is needed. This lessens the risk of an asthma exacerbation and assesses stability. In addition, eNO could be measures to assess increase in airway inflammation. It would be nice if eventually there was a combination SABA/ICS product for use in the USA since earn ICS/LABA is currently not approved.