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When less is more: why doctors might consider stepping down patients’ asthma medication

When less is more: why doctors might consider stepping down patients’ asthma medication

Monday, August 01, 2022

Many Australians whose asthma is well-controlled are being prescribed higher doses of preventer medication than they necessarily need, increasing their risk of adverse effects as well as their out-of-pocket costs, Woolcock Institute of Medical Research’s asthma expert Professor Helen Reddel says. 

In a recent article for the Australian Prescriber, Professor Reddel writes that despite Australian asthma guidelines recommending that doctors consider stepping down preventer treatment after asthma has been well-controlled for two to three months in adults, and for six months in children, as many as 71 per cent of adults and adolescents were taking high-dose combination asthma preventer inhalers. 

"One of the goals of asthma treatment is not just to control symptoms and prevent attacks, but also then to find the lowest dose of treatment that will keep their asthma under control," Professor Reddel says. 

"Often people are started on a high dose, but it’s not well known that most of the benefit of asthma preventer inhalers is seen with low doses." 

There are several possible explanations as to why patients continue to be prescribed high doses. Some patients who initially have frequent symptoms may have been prescribed a high-dose preventer, without the dose being reviewed after their symptoms improved. 

Others may have had their dose increased during a flare up, but because they don’t return to see their doctor after they have recovered, they remain indefinitely on higher doses. In other cases, busy doctors may feel that lowering the dose could trigger a worsening of asthma symptoms. 

"Asthma management is not a case of ‘one size fits all’, and doctors should be trying to customise treatment for the needs of each patient," Professor Reddel says. That said, the dose that will keep asthma well controlled varies between each person, so patients should be monitored closely after any step-down in treatment.

A 2020 study of nearly 40,000 patients (and only the second real-world observational study to examine the health and cost impacts of stepping down medications) found that preventer treatment can generally be stepped down safely with no increased risk of exacerbations or increased need for reliever use.

"When starting treatment, prescribers should emphasise to the patient that one of the goals of asthma management is to first achieve good asthma control, and then find the lowest dose that will keep their asthma well controlled," Professor Reddel says. 

The article in Australian Prescriber, published this month, explains the rationale for doctors to consider a step-down in preventer treatment, which patients are suitable, and how to do it safely.

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