Contemporaneous International Asthma Guidelines Present Differing Recommendations: An Analysis

Table 3

Guideline criteria, levels of evidence, and papers cited for controller de-escalation.

Baseline therapy	CTS 2012	GINA 2012	BTS 2012
Medium/high dose ICS plus LABA	No recommendation provided	Reduce the ICS dose by 50% every 3 months and continue the LABA	No recommendation provided
		Level of evidence: B
		Reference: none provided
Low dose ICS plus LABA	No recommendation provided	If on a low-dose ICS/LABA combination then discontinue the LABA	No recommendation provided
		Level of evidence: D
		Reference: none provided
Medium/high dose ICS alone	No recommendation provided	If the patient is on a medium or high dose ICS alone then reduce the dose of ICS by 50% every three months	Consider decreasing ICS dosing by 25–50% every three months
		Level of evidence: B	Level of evidence: none provided
		References: Hawkins et al. BMJ 2003 [44]; Powell and Gibson  Thorax 2004 [45]; Powell and Gibson  Cochrane Database Syst Rev. 2004 [46]	Reference: Hawkins et al. BMJ 2003 [44]
Low-dose ICS alone	If the patient is adequately controlled on low-dose ICS then one should ensure control for 1-2 years prior to stopping ICS therapy altogether; Level of evidence: none provided; Reference: none provided	If on a low-dose ICS alone and the patient has been controlled for three months then cut down from twice daily to once daily ICS dosing; Level of evidence: A; References: Boulet et al., Respir Med. 2006 [47]; Masoli et al., and Respirology 2004 [48]; If control is achieved on lowest dose ICS and no recurrence of symptoms occurs for one year then one can discontinue regular ICS therapy; Level of evidence: D; References: none provided	No recommendation provided

See Appendix for a description of the evidence rating system used by each guideline.
ICS denotes inhaled corticosteroid; LABA denotes long-acting beta agonist.