FCAAIA Notes: The National Asthma Education and Prevention Program published its first set of guidelines for the diagnosis and management of asthma nearly 25 years ago. There have been several revisions since. However, all iterations of the Guidelines identify patients who should be treated with daily controller medications for asthma. Each iteration also stresses the importance of gradual steps down to the lowest controlling dose.

Importantly, no guideline published anywhere in the world states that patients should just STOP their controller medications without physician guidance. The reason is clear: The risk of poorly controlled asthma is far greater than the risk of the lowest controlling doses of medications. Controller medications are anti-inflammatory medications to control the underlying problem in asthma, As such and as inflammation gradually increases after the medications are stopped, controller medications often stop working more quickly than they start working.

This study tells us something we already knew. Patients who stop their asthma medications are at a greater risk of exacerbation than those who don’t. When your allergist recommends a trial decrease in your asthma medication regimen, you should let him or her know if you are not doing as well. Furthermore, with steps down in medication, you should schedule a follow-up visit that includes repeat pulmonary function testing.

(Source: June 8, 2015. Adapted from Chest. 2015;doi:10.1378/chest.15-0301.)

Thirty-two percent of participants from a retrospective analysis suffered an asthma exacerbation in the 2-year period following a step down process of controller medication, according to study results.

“The current study suggests that the asthma exacerbation risk after stepping down asthma medication is similar to previous reports despite differences in patient selection, study setting and length of follow-up,” Matthew A. Rank, MD, of the Division of Allergy, Asthma, and Clinical Immunology at the Mayo Clinic in Scottsdale, and colleagues wrote.

The researchers conducted a retrospective claims analysis of 26,292 individuals from the Optum Labs Data Warehouse using data from 2000 to 2012 to analyze the time to first asthma exacerbation after stepping down controller medication.

The researchers identified a step down event as a 50% or greater reduction in days-supplied of controller medications from one evaluation period to the next. Researchers followed each individual for 10 consecutive 4-month intervals – three prior to stepping down, one where the step down occurred, and six after the step down.

Of the 32% of the participants who suffered an asthma exacerbation during the subsequent 2 years, 7% had an ED visit or hospitalization for asthma.

Several variables correlated with a shortened time to asthma exacerbation. Participants aged 19 years and younger, of the female sex and of black race had an increased risk for a quicker asthma exacerbation (P < .001 for all).

The researchers do mention there are some limitations that suggest caution with interpreting study results.

“First, we did not include individuals who did not step down in our analysis; therefore, the 32% risk of an asthma exacerbation is an absolute risk not adjusted for baseline risk of those who had asthma exacerbations despite continuation of asthma controller medication,” the researchers wrote. “Finally, using observational data prevents collection of all desired variables, many of which may be important predictors of stability after asthma step down such as spirometry, sputum for eosinophils, exhaled nitric oxide, or other biomarkers.”

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