A
guide to dose adjustments in clinical practice
The dose of ICS needed to gain control of asthma symptoms should be that which is most appropriate to the severity of the underlying disease. This initial dose will be greater than that needed for daily maintenance of asthma control.
A 25% reduction of the ICS dose should be considered when a patient has achieved good control of symptoms for 6-12 weeks. For example, in a patient taking two puffs twice daily, reduce the dose by one puff per day. With some formulations, it may be necessary to change the inhaler strength and/or device to achieve this dose reduction. Further dose reductions (or increases, when needed) should be guided by both symptoms and spirometry. Questioning patients about symptoms and reliever use alone has a lower sensitivity for detecting suboptimal control than the use of spirometry.
During periods of asthma deterioration in adults, medication may need to be adjusted to regain control of asthma. In patients taking ICS alone, the addition of a LABA is recommended. In patients already taking both an ICS and LABA, the ICS dose may need to be increased to regain control. Any increase needs to be individualised for each patient. Increasing the dose of ICS may necessitate the use of a separate ICS inhaler for people using a combination product. In addition, adherence and inhaler technique should be reassessed to ensure that they are not contributing factors to a loss of asthma control. In these circumstances, an increase in ICS dose may not be required.
Management of worsening asthma in children differs from that of adults. Strategies are outlined in the section 'Prescribing in children'.
Dose reduction with combination therapy
Little information is available to guide back titration of LABAs in conjunction with ICS. Theoretically, when reducing the dose of ICS in patients using combination therapy, the dose of ICS should be progressively reduced to the lowest effective dose, which will be around 100-250 mcg HFA-BDP or FP; or 200-400 mcg BUD, for most people. In patients who remain well controlled on low-dose ICS plus LABA, the LABA may then be progressively withdrawn.
Asthma review
Most patients require review of asthma control at least every 6-12 months. However, it is not appropriate that this review of asthma control takes place during an exacerbation. A specific appointment should be set aside for review of asthma control when the patient's asthma is stable. Some individuals may require much more frequent review, especially when adjusting medication doses. Regular review is also important to encourage adherence to treatment.
Each adjustment of dose to achieve minimal effective dose will affect the patient's written asthma action plan, so this will need to be revised when dose adjustments are made.
Role of long-acting beta2 agonist in dose titration
- Consider adding a LABA in any patient who is sub-optimally controlled on ICS dose of 200-250 mcg BDP-HFA or FP; or 400 mcg BUD daily.
- If asthma is optimally controlled on combination treatment, consider withdrawing the LABA once the ICS dose has been reduced to 100-250 mcg BDP-HFA or FP; or 200-400 mcg BUD daily.