Expert Opinion and Evidence-Based Review on Maintenance Therapy Step-Down in Patients With Severe Asthma Controlled With Biologics.

Abstract

INTRODUCTION: Severe asthma (SA) management requires a comprehensive, individualized approach with continuous pharmacological treatment adjustments. In SA patients controlled with biologics, decisions on how to adjust maintenance therapy remain a clinical challenge, as current guidelines provide only general recommendations but lack specific practical guidance on how to implement step-down strategies. MATERIAL AND METHODS: A literature review about maintenance therapy step-down in SA patients was conducted, complemented by five regional expert meetings across Spain. A total of 87 allergists and pulmonologists from referral hospitals discussed four clinical questions: whether step-down is a potential therapeutic goal, the minimum clinical conditions required to initiate tapering, the duration of disease control needed, and the preferred sequence of therapy reduction. Quantitative insights were captured through televoting, complemented by structured discussions. RESULTS: Experts agreed that maintenance therapy step-down can be considered a potential therapeutic objective in patients with SA who achieve sustained control with biologics. Key conditions identified to start it included absence of exacerbations, nonuse of oral corticosteroids, adequate symptom control and preserved lung function for at least 6 or 12 months. A stepwise sequence for stepping-down maintenance therapy was established, prioritizing withdrawal of leukotriene receptor antagonists and high-to-low-dose reduction of inhaled corticosteroids, and finally withdrawal of long-acting beta-agonists, while maintaining low-dose inhaled corticosteroids. CONCLUSIONS: Expert perspectives, together with clinical trial and real-world evidence, support a gradual, individualized approach guided by objective markers and close monitoring. The algorithm proposed will provide clinicians with a structured, evidence-informed framework to guide the safe and effective reduction of SA maintenance therapy in real-world practice.