Correspondence |
Stepping-down inhaled corticosteroid therapy in stable asthma: a secondary care perspective
Sir,Stepping-down inhaled corticosteroid (ICS) therapy in stable asthmatics is often poorly implemented, albeit against a background of limited evidence.1 It is well established in the Global Initiative for Asthma (GINA) guidelines,2 and has recently been adopted by the British Thoracic Society and Scottish Intercollegiate Guidelines Network consortium.1 In the latter guidelines, it is recommended that a 25–50% ICS dose reduction be used at 3-monthly intervals.1 In a large study in primary care, stable asthmatics on moderately high doses of ICS could be safely stepped-down without compromising asthma control.3 However, there are currently no data evaluating stepping-down ICS therapy in stable asthmatics in secondary care.
We assessed asthmatics attending the respiratory clinic, and analysed data for the preceding 12 months. Patients who were actively receiving or had received either oral or parenteral corticosteroids, or immunosuppressive therapy during the 12-month period were excluded. Patients also had to be exacerbation-free during this period. Classification of asthma severity was based on GINA guidelines.2 Sixty consecutive asthmatics were evaluated in clinic. Patients were receiving parenteral corticosteroids (n = 2), immunosuppressant therapy (n = 4), and oral corticosteroids (n = 14), and 28 had asthma exacerbations during the preceding 12 months. Therefore, using strict exclusion criteria, only 12 patients were included in the data analysis.
Three men and nine women with a mean ± SEM age of 56 ± 6 years and FEV1 of 1.97 ± 0.26 l (73 ± 6% predicted) completed the study (Table 1). Mean beclomethasone dipropionate (BDP) equivalent ICS daily dose was 1267 ± 140 µg, and patients had either moderate (n = 6) or severe (n = 6) asthma. Two patients (10 and 11) had a 33% and a 50% reduction in ICS dose from an initial daily dose of BDP 1500 µg and fluticasone propionate 1000 µg, respectively, having had stable asthma for 11 and 8 months correspondingly. The remaining patients continued on the same dose of ICS, despite having had stable asthma during the preceding 12 months. There were no significant differences in any outcomes comparing patients with and without step-down in ICS therapy.
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Our results suggest that stepping-down ICS therapy in stable asthmatics is not being routinely adopted in secondary care. Most of the patients were maintained on their usual dose of ICS, irrespective of the fact that their asthma had been clinically stable during the preceding 12 months. No deterioration in asthma control occurred in the patients who had stepped-down ICS therapy. We appreciate that our patient group was small; this reflects recruitment difficulties, as asthma is a chronic condition that is mainly managed in the community. Furthermore, we acknowledge that asthmatics seen in secondary care may not be a true reflection of the general asthmatic population as a whole. Nevertheless, these asthmatics do fulfill the criteria for step-down in ICS therapy and there was no reason to treat them any differently, according to current guidelines.
The lack of stepping-down of ICS therapy may be attributable to the relatively selective asthmatic population served by secondary care physicians, where most patients have severe, brittle or difficult-to-control asthma. When such patients are using appropriate pharmacotherapy and are clinically stable, there is understandably a disinclination to titrate therapy downwards, in case one offsets the control of asthma, which has been difficult to attain in the first instance. In conclusion, secondary care physicians need to have a heightened awareness in terms of stepping-down ICS therapy in stable asthmatics. Failing to do so may expose patients to unnecessary and prolonged treatment with high doses of ICS.
Department of Respiratory Medicine Ipswich Hospital Heath Road Ipswich email: dkclee{at}doctors.org.uk
Department of Respiratory Medicine Aberdeen Royal Infirmary Foresterhill Aberdeen
References
1. The British Thoracic Society and Scottish Intercollegiate Guidelines Network 2004 update to the British guideline on the management of asthma. [http://www.brit-thoracic.org.uk/docs/asthmafull.pdf]
2. The National Heart, Lung, and Blood Institute and World Health Organisation 2004 update to the Global Initiative for Asthma guideline on the global strategy for asthma management and prevention. [http://www.ginasthma.com/ginawr20.pdf]
3. Hawkins G, McMahon AD, Twaddle S, Wood SF, Ford I, Thomson NC. Stepping down inhaled corticosteroids in asthma: randomised controlled trial. Br Med J 2003; 326:1115–18.
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