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Stepping down to achieve good asthma control: an important role for nurses

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Asthma is a heavy burden on the UK and is often overlooked. There are now 5.4 million people currently receiving treatment for the condition which equates to around one in every 11 children and one in 12 adults.

Primary care nurses can play an important role in stepping down patients who have well maintained asthma, which reduces the risk of potentially harmful side effects.

Why should patients be stepped down?

The original BTS/SIGN guideline recommends considering stepping down asthma treatment when patients have been well controlled for at least 3 months and to reduce the inhaled corticosteroid (ICS) dose by 25–50% each time. This approach allows healthcare professionals to find the dose that balances the need to control asthma while reducing potentially harmful sideeffects associated with over-treatment, but does not provide detailed practical advice on how best to do this.

In a survey of patients taking ICS medicines, over 60% of asthma patients reported concerns about long-term effects of these medicines. Some of the harmful side-effects include oral thrush, cough and voice disturbance, as well as systemic effects such as cataracts and increase in respiratory infections.

A vital role for nurses

Nurses play a key role in asthma care and can actively advise patients on correct inhaler technique, adherence and treatment changes, including stepping down therapy. The key to sustainable control is finding the right treatment level for each patient, which can be accomplished by regular patient review.

Considerations when stepping down asthma therapy

A number of factors come into play when deciding whether to begin stepping down.

“Many of my colleagues in primary care, both doctors and nurses, do sometimes avoid stepping down asthma treatment and this is because they may not be clear about how it is they should tackle it,” says Deirdre Siddaway, Respiratory Nurse Specialist, who has worked with colleagues on an expert panel to develop a new algorithm to support step down of asthma treatment.

She continues, “The best approach may be to keep it simple when stepping down treatment – lower the dose but use the same steroid if possible and the same or similar type of device.”

Recent algorithms have been developed to provide clear and practical advice on stepping down to health professionals.

“My experience is that very few patients need to be on a high dose of ICS. I think that we need to be much more proactive, as nurses; we’ve known the side effects for many years,” said Deirdre Siddaway. “I hope that the new MGP algorithm will encourage more nurses to reduce the dose of ICS to make sure that our asthma patients are not receiving more inhaled steroid than they need.”

Jo Hamilton, who has developed a local algorithm for Dudley Group NHS, said “Our goal is to achieve the best possible outcomes for patients; the new algorithms available aim to provide clear guidance on how and when to help suitable patients to step down, giving nurses and clinicians the confidence to develop the best possible personal asthma action plan for each patient.”


  • Nurses have a vital role in reviewing and stepping down patients
  • Initiating ‘step down’ in appropriate patients is an essential part of the asthma review process
  • Such reductions should be considered every 3 months, each time decreasing the dose by 25–50%
  • Recently developed recommendations and algorithms now provide practical guidance on how to manage this process

Further information regarding the MGP algorithm, providing practical considerations when stepping down asthma treatment can be found at
Napp Pharmaceutical LTD products are discussed within the algorithm and prescribing information can be found on its back cover.


UK/RES-16033 | Date of preparation: June 2016

Source: NAPP Pharmaceuticals Ltd

Stepping Down: James Chalmers and Deirdre Siddaway discuss how, when and why to step down in asthma

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Readers' comments (1)

  • The link after the conclusion to the algorithm doesn't work, says 'page not found', could this be sorted? Thanks.

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