title: Stepping down inhaled corticosteroids from scheduled to as needed in stable asthma: Systematic review and meta-analysis.
abstract: BACKGROUND
  Many patients with asthma are potentially overtreated, which results in unnecessary cost and unnecessary exposure to drugs that may result in adverse events. Step down helps reduce overtreatment, may mitigate these harms, and is advocated by major guidelines. Unfortunately, data that support step down are sparse.
  
  
  OBJECTIVE
  This systematic review aimed to examine the effect of stepping down from scheduled inhaled corticosteroids (ICS) to as-needed ICS in patients with stable asthma.
  
  
  METHODS
  Several electronic databases were systematically searched in April 2014. Articles were screened independently in duplicate. Studies were required to have at least a 12-week follow-up duration and to have compared stepping down from scheduled ICS to as-needed ICS and maintenance of scheduled ICS. Patients were required to have stable asthma as evidenced by at least 4 weeks without asthma exacerbation before intervention.
  
  
  RESULTS
  A total of 3025 abstracts were retrieved initially, 77 of which were retrieved for full-text screening. Of these, only two articles were found to be eligible for inclusion, both were randomized controlled trials. By using random effects meta-analysis, it was determined that, after a follow-up of 6-10 months, the relative risk of exacerbation of stepping down from scheduled to as-needed ICS was 1.32 (95% confidence interval [CI], 0.81-2.16; p = 0.27, I(2) = 0%). Those who did not step down had more symptom-free days (standard mean difference 0.26 [95% CI, 0.02-0.49; p = 0.03; I(2) = 22%]).
  
  
  CONCLUSIONS
  There is currently insufficient evidence to associate stepping down from scheduled to as-needed ICS with a change in exacerbations, although it may lead to fewer symptom-free days.
authors.affiliation: Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Gionfriddo
authors.forename: John B
authors.initials: JB
authors.lastname: Hagan
authors.forename: Christina R
authors.initials: CR
authors.lastname: Hagan
authors.forename: Gerald W
authors.initials: GW
authors.lastname: Volcheck
authors.forename: Ana
authors.initials: A
authors.lastname: Castaneda-Guarderas
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Rank
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D018927:Anti-Asthmatic Agents / Q000008:administration & dosage*; D001249:Asthma / Q000175:diagnosis / Q000188:drug therapy*; D004334:Drug Administration Schedule; D006801:Humans; D016017:Odds Ratio; D017594:Publication Bias; D016896:Treatment Outcome
chemical_list: D000305:Adrenal Cortex Hormones; D018927:Anti-Asthmatic Agents