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In terms of the assessment of current impairment, both the frequency and intensity of symptoms are measured. Risk is the likelihood of asthma exacerbations, progressive decline in lung function (or, for children, reduced lung growth), and/or risk of adverse effects from medication. Impairment is the frequency and intensity of symptoms and functional limitations the patient is experiencing or has recently experienced. Both asthma severity and control are evaluated using the domains of current impairment and future risk. Responsiveness to therapy is the ease with which asthma control is achieved by therapy. Asthma control is defined as the degree to which the manifestations of asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met. Severity is measured most easily and directly in a patient not receiving long-term-controller therapy. Asthma severity is defined as the intrinsic intensity of the disease process. As described in the EPR-3 report, the effective assessment and monitoring of asthma patients are closely linked to the concepts of severity, control, and responsiveness to treatment ( 5). To provide guidance to clinicians regarding proper step-up and step-down strategies, both national and international panels have continued to convene in order to review evidence and to provide structured recommendations based on both the published literature and expert opinion when scientific and clinical data have been lacking ( 1– 4).Ĭrucial for the appropriate management of asthma are consistent measures to assess disease progression and response to therapy. The variability in symptom control is a particularly challenging feature of asthma that necessitates careful monitoring and the need to step-up and step-down individualized therapeutic regimens over time. We will term this particular intervention as “ step-up intermittent (SUI).” Here we summarize the existing data regarding these three approaches to step-up care, step-down management, as well as identify areas where more comparative studies are necessary to provide further guidance to clinicians regarding proper step-up and step-down strategies in the care of asthma.Īsthma is characterized by chronic airway inflammation, variable airflow obstruction, airway hyper-responsiveness and recurrent symptoms ( 1). Finally, for treating symptoms related to the variability of asthma on a day to day basis, ICS used concomitantly with a beta agonist has been evaluated, though not currently approved in the United States. In these cases, a step-up in therapy is usually terminated in 3–10 days once asthma control has been satisfactorily achieved. A second approach, “step-up short-term (SST)”, may be utilized during a temporary loss of acceptable control, such as at the onset of a viral respiratory tract illness. For lack of control that is persistent over long periods of time, an increase in the overall medication or a “ step-up long-term (SLT)” is indicated. This stepwise concept in asthma therapy can be considered in at least three contexts. The variability in symptom control is a challenging feature of asthma that necessitates careful monitoring and the need to step-up and step-down individualized therapeutic regimens over time.