PURPOSE OF THE STUDY.
Identifying strategies to adjust medications when managing chronic diseases poses a challenge to busy practitioners, and often the opportunity is lost to step down therapy. Clinical studies suggest that many patients currently treated with combination controller medications can be successfully stepped down. Use of a multidisciplinary care management team has also been a strategy associated with success in stepping down therapy. Nonadherence represents another method of step-down. This study was performed to identify predictive factors for success in stepping down therapy, the frequency of attempts to step down, and the relative success of guideline-eligible versus non–guideline-eligible step-down attempts.
The study included a retrospective, random sample of 477 participants in the Pediatric Asthma Management Program affiliated with the Mayo Clinic. The children were aged 5 to 8 years with asthma enrolled in a pediatric asthma management program in an integrated primary care practice. All children had persistent asthma, a history of emergency department or hospital visit for asthma during the past 12 months, or uncontrolled asthma symptoms.
By using the National Asthma Education and Prevention Program Asthma Guidelines, participants were identified who were eligible, based on a defined control, to step down therapy. Other participants who did not meet the guidelines for step-down, but who attempted step-down anyway, were also analyzed. Age, gender, pulmonary function, smoking status, time of year, and type of step-down were analyzed for their predictive value.
Slightly more than 55% of the children in the study were eligible, based on the guidelines, to step down therapy, but only 33.7% did attempt to step down. A similar percentage of those who were not guideline eligible also attempted stepping down. Successful step-down occurred in 79.7% of guideline-eligible participants and in 61.7% of those who were non–guideline eligible. Time of year was the only predictive factor (success in any season except for fall), although guideline eligibility was significant in the univariate analysis.
Guideline-based stepping down of asthma medication is an option that should be frequently considered and will be frequently successful.
The important finding in this study is that only a minority of children with asthma that is well controlled have attempted to step down therapy. Stepping down, regardless of whether guideline eligible or not, is often successful. It appears that stepping down in the fall is associated with less success. These findings underline the need for practitioners to regularly assess patients for eligibility to decrease asthma therapy.
- Copyright © 2013 by the American Academy of Pediatrics