“The following story uses fictional names to comply with HIPPA regulations and is not intended to offer medical advice. If you have specific questions regarding your asthma, please contact my office or call your regular doctor. ”
“And what medications are you taking now?” This wasn’t my usual style to get right to the point, but I was running behind schedule.
“Oh, the ones that are in my chart”, replied Mr. Williams with a broad grin that always let me know he was glad to see me. Mr. Williams had been a patient in my office since he started graduate studies in petroleum engineering while he could still breath. Over the years, asthma had taken its toll on this determined white-haired gentleman. A World War II veteran who had survived the Battle of the Bulge (and pictures to prove it), now struggled against an enemy he could not defeat. Every sentence was labored and deliberate as if to say, “not yet; you can’t take my breath away today.” For years, his mantra was always to fight through, stick it out, and never give up, but asthma isn’t like the enemy we can see or hear.
“I don’t want to depend on my medicines”, he declared, almost as if to convince me of his independence. Unlike his steady hand holding his rifle during battle, his lips were now quivering as he demonstrated to me the use of his inhaler to control his asthma. I was worried about his condition, in part because you can’t fight back against inflammation. Since the discovery of antibiotics in the 1940’s, medicine has done a good job of eradicating infections that cause disease. Take your 10 days of antibiotics and you’re home free! Not so with chronic conditions such as asthma, heart disease, or now obesity. Preventive medications don’t always have to be used “forever”, but when do you stop?
Step-down therapy in asthma: A focus on treatment options for patients receiving inhaled corticosteroids and long-acting beta-agonist combination therapy. Allergy Asthma Proc 33:13-18,2012.
This article by Dr. Bacharier may provide some guidelines at least for asthma.
- Asthma activity and treatment responsiveness vary over time and using the least amount of medication to provide control should be the goal of asthma care.
- The clinician needs to carefully consider the need for inhaled steroids + Long-acting bronchodilator combination meds in the first place. (Advair, Symbicort, Dulera)
- Sometimes an inhaled steroid (monotherapy) by itself will do just fine.
- If, however, you are doing well with a combination inhaler (ICS + LABA), you might do better by reducing the dose of steroid and maintain the long-acting bronchodilator as is.
- Your choices of step-down care would include:
- Reduce the steroid dose
- Symbicort 4.5/160 to 4.5/80
- Advair 50/250 to 50/100
- Dulera 5/200 to 5/100
- You might also reduce your dose to ONCE per day rather than morning & evening.
In any clinical scenario, always check with your doctor before making any adjustments in your medications. Many patients with good intentions (like Mr. Williams) stop their asthma medicines, only to find out they can’t breathe. And when you can’t breathe….nothing else matters!