Step-up and step-down approaches in the treatment of asthma

ABSTRACT

Introduction: Significant intraindividual and temporal variability in symptom control is a feature of asthma that requires careful monitoring and the need to periodically review and adjust therapy. Both NHLBI/NAEPP and GINA offer helpful algorithms for a stepping approach to asthma.

Areas covered: The problems arisen in applying the stepwise approach to the treatment of asthma proposed by NHLBI/NAEPP and GINA algorithms and their possible alternatives.

Expert opinion: The current therapeutic stepping approach to asthma, which takes into account lung function, symptoms and quality of life, is certainly useful, but it does not consider the underlying mechanisms. Furthermore, patient’s overestimation or underestimation of the severity of the disease and differences in the opinions on the level of asthma control required between patients and physicians and also between physicians in both primary care and specialist settings are common and may negatively affect asthma control and future risks. A reassessment of the conventional stepping approach to management of asthma is now needed. A pragmatic approach that sets therapeutic goals for each individual and associates them with the treatable traits of asthma which, when therapeutically targeted, will in many cases help to achieve the goals, seems more reasonable than the present stepping approach.

KEYWORDS:

• Asthma
• asthma yardstick
• guidelines
• mart approach
• step-up
• step-down

Article highlights

• Asthma guidelines and strategies recommend a stepwise approach, escalating or de-escalating therapy by moving to a higher or a lower step, respectively, mainly depending on the frequency and severity of the patient’s symptoms change.

• The NHLBI/NAEPP program and the GINA strategy, both updated in 2020, are likely the most popular documents among those available to manage asthma. They provide specific recommendations on initial therapy selection, systematic response assessment, and adjustment of therapies based on individual drug response. However, there are substantial differences between the two documents.

• The Asthma Yardstick is a guideline that advises on how to best use step-up and step-down strategies.

• Regrettably, differences in the opinions on asthma severity determination and impact between patients and physicians and also between physicians in both primary care and specialist settings are common and may negatively affect asthma control and future risks.

• Identifying ‘treatable traits’ that are contributing to respiratory symptoms in each patient with asthma allows overcoming the current ‘one-size-fits-all’ approach to asthma management, and thus fully applying the emerging concept of precision medicine, although we are aware that it is still very difficult to provide personalized care to all asthmatic patients.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or material discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.