Step Down From Scheduled Inhaled Corticosteroids (ICS) Plus As-Needed Fast-Acting Beta-Agonists (FABA) to As-Needed ICS/FABA: A Systematic Review and Meta-Analysis

BACKGROUND: Standard care for stable asthma has been scheduled-dose inhaled corticosteroids (ICSs) plus as-needed fast-acting beta-agonists (FABAs). The efficacy and safety of stepping down from scheduled ICS plus an as-needed FABA compared with as-needed ICS/FABA are unclear. OBJECTIVE: To evaluate the effectiveness and safety of stepping down from scheduled ICS plus as-needed FABA compared with as-needed ICS/FABA in patients with stable asthma. METHODS: We systematically screened MEDLINE, EMBASE, Cochrane Central, and WHO ICTRP for randomized controlled trials comparing outcomes between scheduled ICS plus as-needed FABA and stepping down to as-needed ICS/FABA for patients with stable asthma. Random-effects models-synthesized outcomes included severe exacerbations, asthma control, asthma quality of life, lung function (prebronchodilator FEV₁% predicted), cumulative ICS dose (milligrams per year), and severe adverse events. The Grading of Recommendations, Assessment, Development, and Evaluations approach informed certainty of evidence assessments. RESULTS: We included 7 randomized controlled trials (2485 patients). Meta-analysis showed little to no difference between the scheduled and as-needed ICS groups for severe exacerbations (risk ratio, 0.88; 95% CI, 0.67 to 1.17), asthma quality of life (mean difference [MD], -0.11; 95% CI, -0.28 to 0.07), lung function (MD, -1.24; 95% CI, -3.09 to 0.61), and severe adverse events rate (risk ratio, 1.13; 95% CI, 0.43 to 2.95). Asthma control scores favored scheduled ICS (MD, 0.13; 95% CI, 0.04 to 0.22), though the effect was trivial. Cumulative ICS dose was lower with as-needed ICS (MD, -105.36 mg/y; 95% CI, -120.85 to -89.88). On Grading of Recommendations, Assessment, Development, and Evaluations, all outcomes were rated as having moderate certainty of evidence. CONCLUSIONS: In patients with stable asthma on scheduled ICS and as-needed FABA, stepping down to as-needed ICS/FABA resulted in noninferior asthma control and asthma quality of life with reduced cumulative ICS exposure.