Asthma Treatment
Monitoring to maintain control
Control is not static and patients should be continuously monitored to maintain control and to establish the lowest ‘step’ and dose of treatment necessary. Asthma is a variable disease and treatment should be adjusted accordingly, in response to changing levels of control or worsening of symptoms. Ensuring that a patient is controlled with the lowest treatment necessary minimizes the cost and maximizes the safety of the treatment.1
“There is little experimental data on the optimal timing, sequence, and magnitude of treatment reductions in asthma, and the approach will differ from patient to patient depending on the combination of medications and the doses that were needed to achieve control. These changes should ideally be made by agreement between patient and health care professional, with full discussion of potential consequences including reappearance of symptoms and increased risk of exacerbations.” (GINA 2006 guidelines)1
GINA provide recommendations for stepping down based on the current evidence:
- Further research on stepping-down asthma treatment is needed
- ICS used alone at medium-to-high doses: decrease dose by 50% in 3-month intervals
- Patients controlled on low-dose ICS alone can be stepped down to once-daily dosing
- When asthma is controlled with a combination of an ICS plus a LABA, reduce the ICS dose by 50% and maintain LABA. If control is maintained, reduce the ICS dose further until a low dose is reached. Once a low-dose ICS achieves control, LABA can be discontinued
- Or, discontinue the LABA at an earlier stage and substitute the combination treatment with ICS monotherapy at the same dose contained in the combination
- When asthma is controlled with ICS in combination with controllers other than LABAs, the dose of ICS should be reduced by 50% until a low dose is reached, then the combination treatment stopped as described above
Stepping up in response to loss of control:
- Treatment has to be adjusted periodically in response to worsening control (minor recurrence or worsening of symptoms).1
Non-compliance: we can do better
Steadfast compliance with the therapeutic regimen is important for the optimal management of asthma. Unfortunately, the issue of non-compliance may be a significant barrier to effective therapy. As it is a chronic disease requiring long-term treatment, the very nature of asthma fosters noncompliance. In addition, patients often need multiple medications, some of which may cause local and systemic adverse events. All of these issues have an impact on compliance. In a recent survey, researchers uncovered a number of other factors that may drive non-compliance.2
References:
1. GINA. Global Initiative for Asthma. www.ginasthma.com. 2006.
2. Global asthma physician and patient (GAPP) survey www.gappsurvey.org. 2006.