post-title The Risks and Benefits of Tapering Allergy and Asthma Medications 2014-12-31 10:12:28 yes no Posted by

The Risks and Benefits of Tapering Allergy and Asthma Medications

By: Dr. Deborah Ortega-Carr Although allergic rhinits and asthma are chronic illnesses, most patients are not symptomatic on a daily basis. Many patients have seasonal flares when symptoms are troublesome. Asthma patients are symptomatic a minority of the time, but they are frequently instructed to take a daily controller medication. Often a patient feels that […]

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By: Dr. Deborah Ortega-CarrDeborahOrtegaCarr-300x267

Although allergic rhinits and asthma are chronic illnesses, most patients are not symptomatic on a daily basis. Many patients have seasonal flares when symptoms are troublesome. Asthma patients are symptomatic a minority of the time, but they are frequently instructed to take a daily controller medication. Often a patient feels that they need medicine much less than is prescribed. Patients and parents of patients often wonder how to present these concerns to the physician so that a healthy discussion of risks and benefits of the medications can take place.

Am I Under Control?

The description of control of allergies and asthma varies greatly among individuals. For some it may be the ability to exercise at a high level. For others it may mean a resolution of their worst symptoms. Determing what control means for an individual patient will then set the stage for the plan for management.

Clinicians also vary in their definitions of control but most agree that reducing flares or exacerbations of asthma and allergies is a good marker of control. Recent asthma quidelines suggest that step down of asthma medications may be considered after asthma has been under good control for 3 months. A recent review in the Journal of Allergy and Clinical Immunology: In Practice by Mathew Rank and Stephen Peters discusses the risks, benefits and uncertainties of stepping down asthma therapy.

Reasons to Step Down from a Patients Perspective

Many patients wish to decrease asthma medications to reduce medication side effects or potential side effects. Although these effects are typically mild and more significant side effects are rare, concern may still be present. A very significant concern is decreasing medication cost, especially when multiple medications are required. Patients and parents often worry that they are becoming dependent on medications. Finally, a simpler regimen will place fewer burdens on the patient to maintain the medications.

When and How to Step Down Asthma Medication

Many step down decisions occur outside of a typical clinician-patient interaction and are often made by patients alone. Step down should be considered when symptoms are stable, lung function is normal or near normal, and biomarker assays (such as exhaled nitric oxide) are normal or near normal. However patients and clinicians have several choices when stepping down, both in types of medication and degree of dose reductions. The review by Rank and Peters suggests to that we reduce inhaled corticosteroid (ICS) dose by 25% followed by a period of observation from 2-6 months. Changing dose frequency to once a day should also be considered.

The length of time that the patient has been stable from an asthma standpoint may be a good predicting factor (ie, greater than one year).   The age of the patient and the time of year should be taken into account when deciding on when to step down.

Risks of an Asthma Exacerbation

Asthma exacerbations are unpredictable events and can have serious consequences, including hospitalization and prolonged infection.  Both patients and clinicians wish to avoid these exacerbations.

Additional Therapies Used to Taper Medications

Many clinicians and patients use allergen injection therapy as a way to reduce their need for medication. Tapering medication must only be considered when allergies and asthma are stable and immunotherapy is near maintenance. Finally omalizumab (Xolair) has also been shown to reduce the need for oral and inhaled steroids for asthma.

Help to Start the Discussion

Asking your clinician about the criteria to begin tapering medication can help you and your clinician together form a plan of management which may include stepping down or up as necessary.

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