Back Titration

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One of the recommendations of asthma management guidelines is that an attempt is made to reduce the dose of ICS once asthma control has been achieved, a regime referred to as ''back titration.'' This recommendation applies particularly to patients receiving well in excess of the established therapeutic range. This is an important issue as in western countries, many adult patients with asthma are prescribed ICS doses well beyond the top of the dose-response curve (96,97).

Many doctors and patients have been reluctant to reduce the ICS dose, concerned that this might lead to a loss of control; however, there have been numerous studies supporting the efficacy of such an approach. For example, in a general practice-based study in Scotland, adult patients with asthma on a mean baseline dose of around 1400 mg/day of BDP were able to reduce the dose by an average of 350 mg/day without compromising asthma control (98). The regime used in this 12-month randomized, controlled trial was a 50% reduction in dose if the patient met predetermined criteria for asthma control over the previous two-week period. This study also showed that this step-down management approach could be adopted easily by primary care teams, which are responsible for the care of most asthmatic patients.

In the landmark study of the efficacy of initiating treatment with ICS, after two years of budesonide at a dose of 1200 mg/day, maintenance therapy could be given at a reduced dose of 400 mg/day without loss of control (Fig. 6) (16). However, patients whose budesonide was stopped deteriorated to a symptomatic level comparable to that prior to starting ICS. These studies suggest that in many patients, a significant reduction in ICS dose from above 1000 mg/day can be achieved without a loss of control, but that

Titration Pharmacology

Figure 6 The changes in bronchial hyper-responsiveness associated with treatment regimes: budesonide 1200 mg/day for two years followed by 400 mg/day for one year (—); budesonide 1200 mg/day for two years followed by placebo (...); terbutaline for two years followed by budesonide 1200 mg/day for one year (•-•). Source: From Ref. 16.

Figure 6 The changes in bronchial hyper-responsiveness associated with treatment regimes: budesonide 1200 mg/day for two years followed by 400 mg/day for one year (—); budesonide 1200 mg/day for two years followed by placebo (...); terbutaline for two years followed by budesonide 1200 mg/day for one year (•-•). Source: From Ref. 16.

stopping ICS after a prolonged period of good control is likely to lead to unstable asthma in most patients.

An alternative regime to the variable long-term dosing with ICS has been to modify the dose in accordance with the level of BHR in conjunction with optimizing symptoms and lung function (99). This approach has been shown to lead to more effective control of asthma and a greater improvement in chronic airways inflammation than adjustment of the dose based solely on symptoms and lung function. While the repeat assessment of BHR in the long-term assessment and management of asthma is not feasible in routine practice, it does indicate the potential role of monitoring surrogate markers of inflammation in the long-term management of asthma.

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Coping with Asthma

Coping with Asthma

If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.

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