Asthma Exacerbation, Treatment Failure Prevention During Step-Down Therapy

asthma bronchoconstriction
A hospital emergency department visit in the prior year was associated with subsequent asthma treatment failure.

Adults and adolescents with asthma who are more likely to develop treatment failure and disease exacerbations, and thus may require closer monitoring during step-down therapy, include those with reduced pulmonary function, a history of exacerbations, and early-onset asthma, according to the results of an analysis published in the Annals of the American Thoracic Society.

Investigators used data from the 56-week, multicenter, randomized, double-blind, parallel 3-arm trial, Long-Acting Beta Agonist Step Down Study (LASST; Identifier: NCT01437995). LASST participants were ≥12 years of age and had physician-diagnosed asthma. All were enrolled from December 2011 through May 2014 and were taking a moderate dose combination of inhaled corticosteroids and long-acting beta agonists.

The investigators sought to identify the baseline characteristics associated with treatment failure and exacerbations of asthma during maintenance and guideline-based step-down therapy.

Asthma treatment failure was defined as the following: hospitalization or urgent medical care for asthma, use of systemic corticosteroids for asthma, increase in use of controller therapy, decrease in prebronchodilator forced expiratory volume in 1 second (FEV1) of ≥20% below the value measured at randomization, 2 consecutive days with a 35% decrease in morning peak expiratory flow rate from baseline value (as recorded in daily diaries), use of ≥10 puffs of rescue beta-agonist for 2 consecutive days, participant refusal (eg, medication intolerance or inadequate relief of symptoms), or physician’s judgment (related to safety). Asthma exacerbation was defined as the following: emergency department (ED) visit or hospitalization for asthma or need for systemic corticosteroid use.

A hospital ED visit in the prior year was associated with subsequent treatment failure (hazard ratio, 1.53; 95% CI, 1.06-2.21). Moreover, for every 10% increase in baseline FEV1 percent predicted, the hazard for treatment failure was 14% lower (hazard ratio, 0.86; 95% CI, 0.74-0.99). No difference was reported in the risk for treatment failure between adults and children, nor was duration of asthma related to the risk for treatment failure. Age of asthma onset was also not associated with an increased risk for a patient’s experiencing treatment failure.

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Unexpected ED visits in the prior year was the only risk factor significantly associated with subsequent exacerbations of asthma that required the use of systemic corticosteroids. Furthermore, time to treatment failure or disease exacerbation did not differ between participants with or without self-reports of environmental tobacco smoke exposure.

The investigators noted that a major strength of this analysis was the diverse geographic, racial, and socioeconomic range of patients. Findings of the study may help physicians recognize those patients with asthma who are more likely to develop treatment failure, and thus require closer monitoring.

Disclosures: Funding provided by an unrestricted grant from GlaxoSmithKline.


DiMango E, Rogers L, Reibman J, et al. Risk factors for asthma exacerbation and treatment failure in adults and adolescents with well-controlled asthma during continuation and step down therapy [published online June 4, 2018]. Ann Am Thorac Soc. doi:10.1513/AnnalsATS.201711-886OC