• 23 Aug 2022
  • 15 min 51
  • 23 Aug 2022
  • 15 min 51

Many people with well-controlled asthma are prescribed unnecessarily high doses of inhaled corticosteroids, which can increase the risk of adverse effects and costs for patients. Laura Beaton chats with respiratory physician Helen Reddel about how to step down treatment. Read the full article in Australian Prescriber.


To prevent flare-ups is one of the most important goals, and also to improve asthma control. But once we've achieved that, then the dose can be stepped down and we tailor that dose to the individual patient. Asthma treatment is definitely not one size fits all.

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Asthma is a very common condition, and one of the key goals of management is to find the lowest dose of medication that keeps asthma symptoms well controlled and reduces the risk of severe attacks. We know that most of the benefit of asthma preventers is seen at low doses and not many patients need higher doses. Yet Australian prescribing data shows that the majority of prescriptions for preventer inhalers are actually in the high dose range. Unnecessarily high preventer doses can increase the risk of adverse events and increase the costs for some patients.

Today, we're discussing this problem and some practical advice in how to step down asthma treatment for people with well-controlled asthma. My name's Dr Laura Beaton. I'm a GP in Melbourne and your host for this episode. I'm joined by Professor Helen Reddel, research leader at the Woolcock Institute of Medical Research and the University of Sydney who runs an asthma clinic at the Royal Prince Alfred Hospital in Sydney. Helen is also a member of the Guidelines Committee for the Australian Asthma Handbook, which was one of my go-to guides when I was a GP registrar, and also is a great resource that I still use today. Helen and her co-authors have written an article for Australian Prescriber titled, “How to Step Down Asthma Preventer Treatment in Patients with Well-Controlled Asthma – More is Not Always Better.” Welcome to the podcast, Helen.

Hello, everyone.

So to start off with today, how many people's asthma is well controlled, for whom this article really relates?

We did a very large survey of people with asthma in Australia a few years ago, and around about half of patients had what we would define as well-controlled asthma. In other words, infrequent asthma symptoms, not waking at night because of their asthma, not being limited in their activity due to asthma and not needing their reliever inhaler more than a couple of times a week. So around about half of patients have well-controlled asthma. This includes some people whose asthma is very infrequent. For example, they only have symptoms when they have a cold.

And it makes a lot of sense when thinking about asthma care that we do want to step down treatment for people who have really well-controlled symptoms, but what are the reasons why step-down doesn't always happen for people with good control?

From the patient's perspective and the GP’s perspective, there isn't a perception that this is needed. So it's a sort of a ‘set and forget’ concept with asthma treatment. Now, I realise the pressures of time in primary care, and if the GP or the patient doesn't perceive any particular risk from continuing high-dose treatment, then they may not feel that anything is needed to be done about it.

In clinical practice, I do think there is that tension as well against making sure that you've got good control and really worrying that a lower dose might not be effective and you might set off a flare. How do you explain to patients in your asthma clinic the importance of getting to the lowest effective dose?

So when I see them for the first time, I explain the overall goals of asthma treatment. To prevent flare-ups is one of the most important goals. And for that, every patient with asthma, we now recommend should be on preventer treatment. And also to improve asthma control, as I mentioned earlier. So to minimise the impact of asthma on their day-to-day life. But once we've achieved that, then I explain that often the dose can be stepped down and we tailor that dose to the individual patient. Asthma treatment is definitely not one size fits all.

It sounds like that conversation about stepping down treatment really needs to be flagged at the start when we're stepping up treatment, but also during regular reviews of someone's asthma.

Yes, that's right.

So let's talk through some of the practical steps and timing around planning, stepping down preventer medication. Who are these patients who are the well-controlled group that we want to target and how do we measure them? Can we talk through a bit more about the practical tools we can use in clinic to decide who's got good control?

Yeah. So one of the common tools that's used is the asthma control test, which is available as a short five-item questionnaire. And there's a link to that from the article in Australian Prescriber. What we're aiming for is to consider stepping down in patients whose asthma has been well controlled for the last two or three months and no flare-ups during that time. We also need to consider each patient's risk of exacerbations or flare-ups, and there's a list of those risk factors in the Australian Guidelines.

And certainly, I think you mentioned any night-time symptoms. I think clinically, I use that as my rule of thumb, really any night-time symptoms means that probably there isn't adequate control.

That's right. And certainly the fewer daytime symptoms the patient has, the better you're able to assess their asthma as being well controlled and suitable for a step down.

And let's just also briefly touch on who are the key patient groups that we are not really considering for step down. I think you mentioned severe or difficult-to-control asthma, and those who might be pregnant.

Yes, that's right. So pregnancy, it's only nine months, and because there is this small potential risk of a flare-up when we step down treatment, we postpone stepping down until the end of pregnancy, unless the patient's on an extremely high dose.

Another group that I would be cautious in stepping down is patients who have poor perception of airflow limitation. Around about 15% of people with asthma can't feel it if their lung function goes down by even 20% or more. We can identify these patients in specialist care with lung function testing. And for those patients, you probably don't want to step down their treatment without very, very close monitoring.

And for many of my patients like that, they actually are involved with a respiratory clinic or an asthma clinic, in a secondary or tertiary service. And certainly for those groups, those are groups who I consider step-down care in consultation with specialists, not in primary care alone.

Okay, good.

And let's think about the timing. When's the right time to think about stepping down care, either seasonally or are there other factors that you take into account when thinking about the time to discuss stepping down?

So I always use shared decision making with this. I first find out how comfortable a patient would be with stepping down their asthma treatment. Some patients really don't want to do it. They're very anxious about any change but explaining the risks and benefits can help them accept it. Or in some patients, we don't end up trying a step-down. So with shared decision making, I ask, "What is the best time of the year for you when you would feel most comfortable doing it?" I don't do stepping down in December, for example, because if the patient's asthma becomes unstable, you need them to be able to contact you over the holiday period. If they're just about to go away on holidays, I would postpone until after that. And if they've just got a cold, then you need to wait until they're fully recovered. Many patients will say there's a particular time of year that their asthma is better. For some people, it's during the warm weather, and for others, it's during cool weather.

When thinking about reducing the doses of a preventer medication, how much do we want to reduce by at a time? And how long do we give a person on that dose before we review their control?

When you and the patient have decided to try a step down in treatment, then you should document the patient's level of asthma control, number of days that they need to use their reliever inhaler. I ask them how many steps they can climb, for example, to check that they're not limited in activity. So we document what they're like now, and I get them to write the date on their calendar or in their diary so that they know when they've started the step down. Then usually, I would suggest a step down of no more than about 25%. If they're on an extremely high dose, then I would consider dropping by 50%.

Other factors that affect the amount of reduction would be if the patient is really poorly adherent with their treatment, and yet their asthma is well controlled, then I'm much more confident about a bigger step down as the initial step. And if a patient has very poor inhaler technique, and despite that their asthma is well controlled, again, you can be more comfortable with stepping down by 50% initially. The interval between stepping down, it would normally be around two months if you're stepping down by 50%, for example. And you do want to make sure that you book a follow-up visit for the patient after that period of time, or even a telephone call after a couple of weeks to check that they're okay.

And we've already talked through using certain measures to check on someone's asthma control. How do you use peak flow monitoring for certain patients when working out their step down?

We don't need to use peak flow monitoring in most patients, but the particular groups in whom it is extremely useful are patients that are particularly anxious or where you think that they're at a higher risk of problems if they step down. And on the Woolcock website, we've got a peak flow chart that makes it very easy to see how stable the peak flows are. So I get them to do two weeks of peak flow monitoring before they step down and then mark it on their chart. And you can see very clearly on this chart when peak flow is starting to trend downwards.

Is there a difference between the step-down approach and the timing that you use for children, older children versus adolescents and adults?

I'm not a paediatric respiratory physician. So, I think we need to have advice from paediatricians, but in our Asthma Guidelines, we suggest that in children, asthma should be well controlled for about six months before stepping down and seasonality is quite an issue in paediatric asthma. So you need to consider the time of the year.

I guess also thinking about that written plan, the National Asthma Council's got really great action plan templates online, and those are linked from the handbook as well, which are really helpful.

Yeah. So every patient should have a written asthma action plan before they start a step down. We want every patient to have one anyway, but it's particularly important if you're changing treatment like that.

Is it all right if we briefly talk about those who've got mild asthma who are using reliever-only medication, because I guess overall, this regimen isn't recommended anymore. We know it's probably best to use a low-dose daily inhaled corticosteroid plus a reliever as needed or, actually even better and now in the guidelines for the past few years, the low-dose budesonide/formoterol combination reliever preventer. What do we think about step down in those people? Should they have a step down or not?

The new guidelines that were published a couple of years ago in Australia, which are based on studies in over 10,000 patients, actually provide a really good option for stepping down treatment in patients with mild asthma. Previously, we knew that if you stopped the preventer treatment completely, many of those patients would end up having a severe flare-up, need prednisone and that's associated with long-term adverse effects.

Now, we have an additional option for stepping down from low-dose preventer treatment, and that is to switch the patient to an as-needed regimen using low-dose budesonide/formoterol for symptom relief. So it relieves symptoms as well as a salbutamol inhaler, but it dramatically reduces the risk of having a severe attack compared with just using a salbutamol inhaler alone. So this is really a big advance in terms of our options for patients with mild asthma.

And can you just remind me and our listeners, that's because the formoterol, while a longer acting beta agonist, has a really quick onset. Is that how it works?

Yes. Formoterol can be used for symptom relief. It is the only long-acting beta agonist that can be used as a combination reliever like this. There are other long-acting beta agonists that have a quick onset, but they can only be used once a day, for example vilanterol. Budesonide/formoterol in Australia is the only medication with several brands that can be used as needed for treatment of mild asthma. The essential part though, of this reducing risk of severe attacks by almost three quarters, is that you get a combination of preventer and reliever whenever the patient takes their inhaler. And that is not only relieving symptoms, but preventing those symptoms worsening into a severe attack.

Do you mind talking a little bit about how sometimes the upfront costs, maybe these puffers might be a little bit more, but in fact they're going to last a lot longer and actually give better control than a SABA alone, which is what many of these people have been using for a long time.

The upfront cost of the low-dose budesonide/formoterol inhalers can be a barrier for some patients, but in the studies of mild asthma, the inhaler was used only three to four times a week on average. And these were in people who had symptoms much more often than that at entry to the study. So even though the upfront cost is higher than the upfront cost of buying a salbutamol inhaler, there's this dramatic reduction in the risk of having a severe attack.

In Australia, SABA alone is just not recommended except for a very tiny proportion of patients who have symptoms less than twice a month and no risk factors for having flare-ups. And that includes having had a flare-up in the last 12 months, but there's a lot of other risk factors. In the international guidelines that I chair, we in fact have recommended against using SABA alone, salbutamol alone, for any patient with asthma, because the risk of severe attacks is very substantial and can be dramatically reduced by this new regimen.

In the past, the only option for them was to be taking a preventer treatment every single day to reduce the risk of severe attacks. With the new regimen of as-needed, low-dose budesonide/formoterol, which has been approved in Australia for a couple of years and subsidised by the PBS, the cost to the patient if you average it over a month is actually lower and they don't have that risk of having severe attacks, needing prednisone treatment.

And I'd like to point all of our listeners to a really excellent table in your article that goes through stepwise all of the different types of asthma regimens that there are and step-down suggestions for each situation. Helen, thank you so much for your time today. I really appreciate it.

Thank you.


Dr. Laura Beaton (16:51):

In the last three years, Helen Reddel's institute has received independent research funding from AstraZeneca, GlaxoSmithKline and Novartis. She or her institute have received honoraria for participation in advisory boards for AstraZeneca, Chiesi, GlaxoSmithKline, Novartis and Sanofi Genzyme; honoraria from AstraZeneca, Behringer Ingelheim, Chiesi, GlaxoSmithKline, Sanofi Genzyme and Teva for independent medical education presentations; consulting fees from AstraZeneca and Novartis. Helen Reddel is chair of the Global Initiative for Asthma Science Committee and a member of the Australian Asthma Handbook Guidelines Committee.

The views of the host and the guest on this podcast are their own and may not represent Australian Prescriber or NPS MedicineWise.