Dose titration and patient expectations 

Gaining control

• The addition of a LABA leads to significant improvements in control in most patients. 
• The initial dose of combination therapy used may be higher than the final maintenance dose. The aim will be to gradually reduce the dose of combination medication once control is achieved. 
• ‘Control’ will be measured by improvements in lung function (PEF, FEV₁) and a decrease in the frequency and severity of symptoms. Good control is characterised by reliever use less than 3 times a week, as indicated in the Asthma Management Handbook.²⁰ This is an important goal of therapy. 

NB. When commencing combination therapy, advise patients to keep their ICS inhaler as it may be required when reducing the dose of combination therapy to a maintenance level.

Assessing control – 
1- 3 months after adding a LABA to ICS

•  If patients are persistently symptomatic or continue to require reliever medication daily, consider other contributing causes/triggers and/or specialist referral. Further increases in doses may be beneficial, but current evidence does not support exceeding recommended maintenance doses (eformoterol 24mcg BD, salmeterol 50mcg BD).
• If stability is achieved with optimal lung function for the individual patient, consider a reduction in ICS. 

Back titration – 
reducing to a maintenance dose

• Once control is achieved, reduction of the daily dose to the lowest effective dose is the next aim.
• Back titrate by reducing to the next lowest dose of combination therapy. Some patients may require the addition of a separate ICS inhaler to facilitate gradual reduction of the corticosteroid component.

Maintenance

• Maintain at the lowest effective ICS dose and reinforce trigger factor avoidance and management
• Schedule a follow-up appointment to assess the appropriate dose of each component (LABA and ICS).