Step-in step-down approach in the management of bronchial asthma in adolescents and adults

Despite the step-up step-down approach of asthma management suggested by the Global Initiative for Asthma (GINA), control of asthma continues to be poor. It was hypothesized that a new "Step-in Step-down approach" could prove to be a better alternative. The present study was carried out with the objective to assess the efficacy and adverse effects of this new approach in the control of asthma.

All treatment-naïve asthma patients were randomly allocated to either Group I (patients received budesonide 400 μg + formoterol 6 μg twice daily via dry powder inhalation device along with as-needed salbutamol) or Group II (patients received stepwise treatment as per GINA guidelines, 2017). Patients were monitored on a fortnightly basis for control of symptoms, spirometry, and complications if any. Asthma Control Questionnaire (ACQ-7) was used to assess control of asthma. Adverse effects, if any, were recorded and managed appropriately. Step-down was attempted on achieving sustained control of asthma, i.e., ACQ score of <0.75 on two consecutive fortnight assessments in both the groups. In Group I patients, long-acting β2-agonist was withdrawn first. Subsequently, a dose of budesonide was also reduced. In Group II patients, the treatment was decreased to the next lower step medicines as per the GINA guidelines.

After exclusions, a total of 787 patients were randomized to either Group I or II. The demographic profile of patients in the two groups was similar. Patients on "step-in step-down" approach had a statistically significant advantage over those on conventional step-up step-down approach in terms of (a) time to the first control (271 vs. 98 within first 4 weeks), (b) need for rescue steroids (two patients in Group 1 vs. 40 in Group 2), (c) number of exacerbations (30 vs. 232), and (d) use of rescue SABA (Only 30 patients in group I required > 5 inhalations per week as compared to all in group II). Adverse reactions were not observed in any of the patients in either group.

We conclude that step-in step-down approach is a more robust and safer approach for control of asthma.