Intended for healthcare professionals

Clinical Review State of the Art Review

Why and how to step down chronic asthma drugs

BMJ 2017; 359 doi: (Published 16 October 2017) Cite this as: BMJ 2017;359:j4438
  1. Michael R Gionfriddo, assistant professor1,
  2. John B Hagan, associate professor2,
  3. Matthew A Rank, associate professor3
  1. 1Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Forty Fort, PA, USA
  2. 2Division of Allergic Diseases, Mayo Clinic, Rochester, MN, USA
  3. 3Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, AZ, USA
  1. Correspondence to: M A Rank rank.matthew{at}


Asthma is a common chronic airways disease. The goal of asthma management is to control symptoms while minimizing the side effects of treatment. Following a period of stable asthma, clinicians should consider stepping down treatment. This approach is recommended by current guidelines. Step-down has been studied for several types of asthma drug regimens, and certain approaches may have lower risk than others. Systematic reviews of multiple trials support the following specific step-down approaches: optimizing inhaled corticosteroid dosing when stepping down oral corticosteroid, reducing inhaled corticosteroid from a higher dose, lowering inhaled corticosteroid-long acting bronchodilator (ICS-LABA) dose while adding ICS-LABA on-demand, adding leukotriene receptor antagonist (LTRA) while lowering inhaled corticosteroid dose, and using allergen immunotherapy when reducing inhaled corticosteroid from a higher dose. Systematic reviews of multiple trials support an increased risk of asthma exacerbation for patients who completely stop taking inhaled corticosteroid or long acting bronchodilator. Strategies to implement step-down in practice include the use of risk prediction as well as tools to support shared decision making and communication about risk between clinicians and patients.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • We acknowledge the contributions from the Community Engaged Research Advisory Board (Rochester, MN) and the Mayo Clinic Family Medicine Advisory Board (Phoenix, AZ) in the development of the patient centric model of stepping down asthma drugs.

  • Contributors: MRG and JBH contributed equally to the article. All authors substantially contributed to the design of the work, interpretation of the data, and drafting of the manuscript. All authors revised the manuscript critically for important intellectual content and approved the final version. All three authors are guarantors.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: MRG has received research support from AstraZeneca, has sat on advisory boards sponsored by Pfizer in the area of shared decision making, and has had travel and an honorarium paid by the Pharmaceutical Research and Manufacturers of America Foundation to Geisinger for speaking on drug adherence at a symposium; JBH has had research support paid to his institution by GlaxoSmithKline, Astra-Zeneca, Medimmune, Sanofi, and the NIH.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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