ICS dose reduction compared with no change in ICS dose (no concomitant LABA) for adults with asthma

Patient or population: adults with asthma
Setting: primary care and specialist centres
Intervention: ICS dose reduction
Comparison: no change in ICS dose (no concomitant LABA)

Exacerbation requiring OCS
Follow‐up: range 10 weeks to 12 weeks

OR 1.86
(0.16 to 21.09)

261
(2 RCTs)

⊕⊝⊝⊝
Very low^a

No clear benefit or harm of stepping down the dose of ICS (very low‐quality evidence)

Asthma control
assessed by: Asthma Symptom Scale from: 0 (no symptoms) to 5 (severe symptoms)
Follow‐up: 10 weeks

‐

150
(1 RCT)

⊕⊕⊝⊝
Low^b

No clear benefit or harm of stepping down the dose of ICS (low‐quality evidence)

All‐cause SAEs
Follow‐up: mean 12 weeks

OR 1.24
(0.25 to 6.25)

742
(2 RCTs)

⊕⊕⊝⊝
Low^c

No clear benefit or harm of stepping down the dose of ICS (low‐quality evidence)

Steroid‐related AEs
Follow‐up: range 10 weeks to 12 weeks

OR 0.76
(0.16 to 3.54)

261
(2 RCTs)

⊕⊝⊝⊝
Very low^d

No clear benefit or harm of stepping down the dose of ICS (very low‐quality evidence)

Health‐related quality of life (change from baseline)
assessed by: AQLQ
Follow‐up: 12 weeks

‐

554
(1 RCT)

⊕⊝⊝⊝
Very low^e

No clear benefit or harm of stepping down the dose of ICS (very low‐quality evidence); MCID is 0.5 for AQLQ

Lung function, FEV₁ (L)
assessed by: spirometry
Follow‐up: range 10 weeks to 12 weeks

‐

261
(2 RCTs)

⊕⊕⊝⊝
Low^f

No clear benefit or harm of stepping down the dose of ICS (low‐quality evidence)

Exacerbations requiring hospitalisation ‐ not reported

‐

‐

‐

Outcome not reported by included studies

*Risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
^aThe quality of the evidence was downgraded once for indirectness (included studies were performed at specialist centres) and twice for imprecision (no events reported by Magnussen 2000; confidence intervals include null effect and appreciable benefit or harm).

^bThe quality of the evidence was downgraded once for risk of bias (selective reporting) and once for indirectness (single study representative of one setting and drug regimen).

^cThe quality of the evidence was downgraded once for risk of bias (selective reporting) and once for imprecision (confidence intervals include null effect and appreciable benefit or harm).

^dThe quality of the evidence was downgraded once for risk of bias (selective reporting), once for indirectness (representative of specialist centres) and once for imprecision (confidence intervals include null effect and appreciable benefit or harm).

^eThe quality of the evidence was downgraded twice for risk of bias (selective reporting and lack of blinding (subjective outcome)) and once for indirectness (single study representative of one setting and drug regimen).

^fThe quality of the evidence was downgraded once for risk of bias (selective reporting) and once for imprecision (confidence intervals include null effect and appreciable benefit or harm).
AE, adverse event; AQLQ, Asthma Quality of Life Questionnaire; CI, confidence interval; FEV₁, forced expiratory volume in one second; GRADE, Grades of Recommendation, Assessment, Development and Evaluation; ICS, inhaled corticosteroid; LABA, long‐acting beta agonist; MCID, minimum clinically important difference; MD, mean difference; OCS, oral corticosteroid; OR, odds ratio; RCT, randomised controlled trial; RR, risk ratio; SAE, serious adverse event.

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to the estimate of effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

ICS dose reduction compared with no change in ICS dose (concomitant LABA) for adults with asthma

Patient or population: adults with asthma
Setting: primary and secondary care
Intervention: ICS dose reduction
Comparison: no change in ICS dose (concomitant LABA)

Exacerbation requiring OCS
Follow‐up: range 4 months to 12 months

OR 1.31
(0.82 to 2.08)

569
(2 RCTs)

⊕⊕⊝⊝
Low^a

No clear benefit or harm of stepping down the dose of ICS with respect to exacerbations requiring OCS (low‐quality evidence)

Asthma control (short asthma morbidity score)
Follow‐up: 12 months

‐

242
(1 RCT)

⊕⊕⊝⊝
Low^b

No clear benefit or harm of stepping down the dose of ICS with respect to asthma control (low‐quality evidence)

All‐cause SAEs
Follow‐up: range 4 months to 12 months

OR 0.60
(0.11 to 3.33)

569
(2 RCTs)

⊕⊕⊝⊝
Low^a

No clear benefit or harm of stepping down the dose of ICS with respect to all‐cause SAEs (low‐quality evidence)

Steroid‐related AEs ‐ not reported

‐

‐

‐

St. George's Respiratory Scale score (change from baseline)
Follow‐up: 12 months

Score 0‐100. 100 = greatest impact of chest disease on life; MCID is 4 units.

‐

229
(1 RCT)

⊕⊕⊝⊝
Low^b

No clear benefit or harm of stepping down the dose of ICS with respect to HRQoL (low‐quality evidence)

Exacerbation requiring hospitalisation
Follow‐up: range 4 months to 12 months

OR 4.06
(0.45 to 36.86)

569
(2 RCTs)

⊕⊕⊝⊝
Low^d

No clear benefit or harm of stepping down the dose of ICS with respect to exacerbations requiring hospitalisation (low‐quality evidence)

Lung function, reduction in FEV₁ (% predicted, change from baseline)
Follow‐up: 3 months

‐

14
(1 RCT)

⊕⊝⊝⊝
Very low^e

No clear benefit or harm of stepping down the dose of ICS with respect to lung function (very low‐quality evidence)

*Risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
^aThe quality of the evidence was downgraded once for risk of bias (selective reporting) and once for imprecision (confidence intervals include null effect and appreciable benefit or harm).

^bThe quality of the evidence was downgraded once for risk of bias (selective reporting) and once for indirectness (single study representative of one setting and drug regimen).

^cNote that study authors reported the change to the lowest SGRQ score during follow‐up.

^dThe quality of the evidence was downgraded once for risk of bias (selective reporting) and once for imprecision (confidence intervals include null effect and appreciable benefit or harm).

^eThe quality of the evidence was downgraded once for risk of bias (selective reporting), once for indirectness (single study representative of one setting or drug regimen) and once for imprecision (wide CI).

AE, adverse event; CI, confidence interval; FEV₁, forced expiratory volume in one second; GRADE, Grades of Recommendation, Assessment, Development and Evaluation; HRQoL, health‐related quality of life; ICS, inhaled corticosteroid; LABA, long‐acting beta agonist; MCID, minimum clinically important difference; MD, mean difference; OCS, oral corticosteroid; OR, odds ratio; RCT, randomised controlled trial; RR, risk ratio; SAE, serious adverse event.

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect