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. This stepwise concept in asthma therapy can be considered in at least 3 contexts. For lack of control that is persistent over long periods of time, an increase in the overall medication or a step-up long-term strategy is indicated. A second approach, the step-up short-term strategy, can be used during a temporary loss of acceptable control, such as at the onset of a viral respiratory tract illness. In these cases a step-up in therapy is usually terminated in 3 to 10 days once asthma control has been satisfactorily achieved. Finally, for treating symptoms related to the variability of asthma on a day-to-day basis, inhaled corticosteroids used concomitantly with a beta-agonist have been evaluated, although this treatment is not currently approved in the United States. We will term this particular intervention a step-up intermittent strategy. Here we summarize the existing data regarding these 3 approaches to step up care and step down management, as well as to 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.
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