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Customizing Asthma Treatment

Step-Up / Step-Down Treatment Approach

By Anna Loengard, M.D.

Updated February 21, 2008

(LifeWire) - Asthma treatment and asthma symptoms vary from person to person. They can also differ in the same person depending on the time of day, day of the week or month of the year. This variability indicates the importance to have asthma treatment plans that are flexible and personalized to address a person's unique issues.

Customizing asthma treatment with a variable plan that is tailored to a person's current severity of asthma symptoms is called the step-up/step-down treatment approach. In this approach to asthma treatment, medications are increased in times of greater inflammation and decreased when symptoms are more stable.

The step-up/step-down treatment approach was introduced because of concerns about exposure to medications over years and even decades for those who started taking medications in their childhood. The possibility that a medication could cause side effects is a reality with all asthma treatments. These side effects can also increase with long-term use.

The key to a successful step-up/step-down treatment plan is to closely monitor symptoms. The more aware a person is about his own asthma triggers and symptoms, the better. This makes it easier to work with a doctor and to get adjusted treatments accordingly.

By keeping a close eye on asthma control, treatments can be changed as requirements change. This makes it possible to minimize the use of both inhaled and oral steroids.

Regular Doctor Visits Are Essential

A study of the medical records of people with persistent asthma revealed that most of these people were not seeing their doctors regularly enough. The cause of most visits were the worsening of asthma symptoms, requiring a step-up therapy for the patients. Researchers found that routine visits were limited in which doctors could recommend a step-down therapy, due to lack of opportunity, as it was also found that people often initiated step-down therapy on their own without consulting their doctor.

In light of this study, it's clear that step-up/step-down therapy can be effective, but people need to find a primary doctor who can be easily consulted and trusted. People with persistent asthma should be seeing their doctor every 3 months to reassess treatments and see if changes are needed. According to the National Heart, Blood, and Lung Institute Expert Panel Report, anyone with asthma should keep track of the following items, which should be reviewed by the doctor at each visit:

  • How often asthma symptoms require rescue inhalers
  • Frequency of night-time symptoms
  • Any interferences that the asthma is causing to disrupt a person's normal activities
  • Peak flow measurements of lung function

With a track record of this information, the doctor can determine if the asthma treatment plan is working and what changes (if any) need to be made.

Step-Up Treatment

If someone with asthma needs to use rescue inhalers more than twice a week, or if the person is waking up with asthma once a week or more, the asthma is not being adequately controlled. In addition, if the asthma is interfering with a person's usual activities or if the person's peak flows are less than 80% of that person's normal measurements, a step-up treatment regimen is probably needed. A step-up treatment may involve any or all of the following:

  • An increase in the inhaled corticosteroid dose
  • Addition of a second inhaler or medication (such as long-acting beta agonists)
  • A brief course of oral steroids

Ideally, anyone whose medication has been increased should be re-evaluated by the doctor in the next 2 to 4 weeks.

Step-Down Treatment

A large study involving people with moderate persistent asthma examined the effects of step-down therapy over the course of 1 year. Half of the people studied had reduced their inhaled corticosteroid dose by 25%. The other half remained on the initial high-dose therapy. At the end of 1 year, there was no difference between the two groups in the number of asthma attacks, the amount of oral steroids needed or the number of hospital visits.

A person whose asthma was kept stable with a dose of inhaled corticosteroids for 3 months or more may be able to decrease that dose by 25% to 50% over time. However, it is important to attempt this only under the guidance of a doctor.

Anyone who is undergoing a decrease in the dose of any inhalers, or whose medication(s) have changed, should let his doctor know immediately if symptoms start to increase. For anyone who has been on maintenance inhaled steroids, there is always a risk of asthma attacks when they are stopped entirely.

Step-down therapy is likely to focus on reducing the dose of inhaled corticosteroids. Although it may seem counterintuitive, reducing the steroid dose may involve adding new medications. Studies have found that the addition of a long-acting beta-agonist (such as salmeterol or triamcinolone) can help decrease the amount of inhaled steroid required by as much as 50%.

Once a person has become stable on this new inhaler program, the doctor can start reducing the steroid inhaler. For someone who is already taking additional drugs, whether inhalers or pills, the doctor may slowly decrease these once good asthma control has been achieved with the lowest possible dose of inhaled steroids.

For anyone with persistent asthma, chronic maintenance therapy is recommended. A doctor should always be consulted before stopping asthma medication altogether.

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Sources:

"Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma." Aug. 2007. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, U.S. Department of Health and Human Services, National Institutes of Health 18 Dec. 2007. <http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf>.

Hawkins, Gillian, Alex D. McMahon, Sarah Twaddle, Stuart F. Wood, Ian Ford, and Neil C. Thomson. "Stepping Down Inhaled Corticosteroids in Asthma: Randomised Controlled Trial." BMJ (2003) 326:1115. 18 Dec. 2007 <http://www.bmj.com/cgi/content/full/326/7399/1115>.

Lemanske, Robert F., Jr, Christine A. Sorkness, Elizabeth A. Mauger, Stephen C. Lazarus, Homer A. Boushey, John V. Fahy, Jeffrey M. Drazen, Vernon M. Chinchilli, Timothy Craig, James E. Fish, Jean G. Ford, Elliot Israel, Monica Kraft, Richard J. Martin, Sami A. Nachman, Stephen P. Peters, Joseph D. Spahn, and Stanley J. Szefler, for the Asthma Clinical Research Network of the National Heart, Lung, and Blood Institute. "Inhaled Corticosteroid Reduction and Elimination in Patients With Persistent Asthma Receiving Salmeterol: A Randomized Controlled Trial. The Journal of the American Medical Association (2001) 285(20):2594-2603. <http://jama.ama-assn.org/cgi/content/full/285/20/2594>.

Yawn, Barbara P., Peter C. Wollan, Susan L. Bertram, David Lowe, Joseph H. Butterfield, Denise Bonde, and James T. C. Li. "Asthma Treatment in a Population-Based Cohort: Putting Step-Up and Step-Down Treatment Changes in Context." Mayo Clinic Proceedings (2007) 82:414-421. 18 Dec. 2007 <http://www.mayoclinicproceedings.com/inside.asp?AID=4337&UID=>.

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