Supervised step-down of inhaled corticosteroids in the community:an observational study

Introduction: Current asthma guidelines recommend step-down of inhaled corticosteroids (ICS) to the minimum dose required for control of symptoms.Aim: To determine if supervised step-down of (ICS) in the community has any effect on asthmatic inflammation.Methods: 119 Community based asthmatics underwent progressive step-down of therapy until they became unstable or reached an (ICS) dose of <= 200 mu g beclomethasone dipropionate (BDP) or equivalent. Once unstable, participants stepped back up to the last stable dose of ICS. Exhaled nitric oxide (NO) and mannitol challenge were performed at the start and end of step-down. Asthma Quality of Life Questionnaire (AQLQ) and spirometry were recorded at each step-down visit.Results: The median (interquartile range) BDP equivalent dose was significantly higher pre vs. post step-down: 400 mu g (400-800) and 250 mu g (200-400) per day respectively (P < 0.05). Examination of change in PD10 in individual patients revealed that 34% had an improvement (>+1 dd), 47% had no change (+/--1 dd), and 19% had a worsening (<-1 dd). The geometric mean fold ratio in NO for pre vs. post was 0.96 (95% Cl 0.87 to 1.06, P = 0.43). Mean (SEM) values for FEV1 were 86.2% (1.51) vs. 84.5% (1.46) (P = 0.04). There was a significant improvement in AQLQ.Conclusions: We have demonstrated that a significant reduction in ICS dose may be achieved in a community setting without any worsening of airways inflammation or lung function, and with an associated improvement quality of life in the majority of patients. This apparent disconnect may reflect enhanced adherence due to supervision of step-down. (c) 2010 Elsevier Ltd. All rights reserved.