Editorial
The dilemma of reducing treatment for patients with moderate-severe controlled asthma
El dilema de la reducción de tratamiento en pacientes con asma moderado-grave controlados
S. Marín Romero
Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain
L. Jara Palomaresa,b,
Corresponding author
luisoneumo@hotmail.com
Corresponding author at: Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
Corresponding author at: Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
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Marín Romero" "autores" => array:1 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Marín Romero" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "autoresLista" => "L. Jara Palomares" "autores" => array:1 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Jara Palomares" "email" => array:1 [ 0 => "luisoneumo@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0010" ] 1 => array:3 [ "entidad" => "CIBERES, Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El dilema de la reducción de tratamiento en pacientes con asma moderado-grave controlados" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Asthma is a significant public health problem that affects all ages, and its prevalence is increasing in many countries, with a predominant increase in children. Asthma currently incurs significant healthcare expenditures due to its morbidity and mortality and from an economic standpoint. However, a reduction in mortality and hospitalizations has been observed in a number of countries. The objective of asthma treatment is maintaining control for long periods.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> International guidelines recommend gradually decreasing the treatment once the asthma has been controlled for at least 3 months, so as to find the minimum therapeutic needs required to maintain control (step-down therapy). However, this suggestion has a low level of evidence.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> A meta-analysis in the Cochrane journal concluded that adults undergoing treatment with long-acting β2-adrenergic agonists (LABA) and inhaled corticosteroids (ICS) for whom the treatment with the LABA was suspended had an increased likelihood of asthmatic exacerbations.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the journal, we present an interesting study that analyzed the factors that determined the loss of control when conducting step-down therapy when treating moderate-severe asthma with a combination of ICS and LABA. This retrospective multicenter study analyzed 374 patients and found that the therapy failed for 41.7% of the patients, defining failure as the need to increase the treatment, loss of asthma control measured by an asthma control test (ACT) score<span class="elsevierStyleHsp" style=""></span><20 and/or the presence of exacerbation. This study identified the following factors related to treatment failure: age (the greater the age, the higher the risk), severe asthma (compared with moderate asthma) and asthma controlled for less than 6 months. Although the study had the limitation of being retrospective, it helps identify the factors to consider when deciding to reduce the treatment, although these findings need to be confirmed in prospective studies or clinical trials.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Recently, Pérez de Llano et al. conducted a prospective, multicenter study on adult patients with controlled asthma, analyzing variables associated with the failure of step-down therapy.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The authors analyzed 228 patients in the derivation cohort (495 episodes of step-down therapy) and identified the following factors associated with step-down therapy failure: a forced expiratory volume in one second (FEV<span class="elsevierStyleInf">1</span>)/ forced vital capacity (FVC) ratio<span class="elsevierStyleHsp" style=""></span><70% (+2.5 points), an FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span><80% of the theoretical value (+2 points), 1 or more severe exacerbations in the past year (+3 points) and an ACT score <25 (+2.5 points). According to this scale, the patients with a score <4.5 points had a risk of step-down therapy failure of <20%, and those with a score >8 had a >40% risk of step-down therapy failure. Nevertheless, this scale needs to be validated in a different prospective cohort to have external validity.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion, asthma is a complex disease to manage and requires follow-up, especially to maintain good symptom control. However, for those patients with good disease control, we face the challenge of deciding when to conduct step-down therapy and what tools to use.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-07-19" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Marín Romero S, Jara Palomares L. El dilema de la reducción de tratamiento en pacientes con asma moderado-grave controlados. Rev Clin Esp. 2020;220:117–118.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global Strategy for Asthma Management and Prevention 2019 update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Global Initiative for Asthma" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2019" "paginaInicial" => "1" "paginaFinal" => "199" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comité Ejecutivo de GEMA. [GEMA(4.0). Guidelines for Asthma Management]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "V. 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