Making decisions about stepping down asthma medicines

Published Online April 11, 2013

Asthma is a chronic problem that includes symptoms such as shortness of breath, coughing, wheezing, and chest tightness. The severity of these symptoms tends to vary from day-to-day. The goal of most patients and providers is to control these symptoms (especially when they are most severe during asthma attacks) with the least amount of medicine possible. There are times when both patients and providers will consider “stepping down” chronic asthma medicines. Stepping down asthma medicines may include decreasing the amount of medicine or stopping the medicine altogether. There are very few studies that have examined the decision-making process involved in stepping down chronic asthma medicines.

Rank et al conducted a survey among people with asthma who lived in southwestern Minnesota and reported their findings in The Journal of Allergy and Clinical Immunology: In Practice. The survey included questions about asthma symptoms (including asthma attacks), the quality of health care delivery, and lowering or stopping chronic asthma medicines. The authors examined the relationship between the decision to decrease their chronic asthma medicines and a number of factors reported by patients in the survey: age, gender, insurance type, the quality of the health care delivered by their provider, having an asthma action plan, the burden of the treatment, compliance to the asthma medicines, control of asthma symptoms, asthma attacks, missed school/work days, health literacy, and number of years with asthma.

Most of the 102 survey responders (73%) were taking daily asthma controller medicines and therefore likely had persistent asthma, and most reported poor asthma control (71%). Twenty-four responders decreased the dose of their asthma medicine, and 28 stopped the asthma medicine completely (including 12 who did both over the course of the past year). Only 24% of those who decreased their asthma medicine decided to do so on their own (without input from their health care provider), while 61% of those who stopped their asthma medicine altogether decided on their own. Only having an asthma action plan was associated with the decision to decrease or stop asthma medicines. The authors found no association between the decision to decrease or stop asthma medicines and any of the other factors listed above.

The authors found that decreasing or stopping chronic asthma medicines is common in a community setting (39% during a 1 year period). Decisions to decrease asthma medicines were made independently by patients, by the provider, or together in fairly equal fractions while decisions to stop asthma medicines were made primarily by patients independently. This finding suggests that stopping asthma medicine may be a different type of decision than lowering asthma medicine dosing. The other finding of note is that having been given an asthma action plan is associated with an increased likelihood of stepping down asthma medicines. The authors speculate that having an asthma action plan may promote increased confidence in both patients and health care providers when deciding to step down asthma medicine. The asthma action plan can play a central role in providing anticipatory guidance to patients and may be especially important when considering a step down of asthma medicines.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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