Does the current stepwise approach to asthma pharmacotherapy encourage over-treatment?

For the past 20 years, asthma pharmacotherapy has been described in clinical practice guidelines in terms of a stepwise approach, with medications and/or doses increased if asthma is not well-controlled, and reduced once good control is achieved and maintained. Although many patients with asthma are untreated, there are also significant problems with over-treatment once regular controller therapy is commenced. This increases the cost of treatment and exposes patients to unnecessary risks of side-effects. The present pro-con debate addresses the question of whether the stepwise approach itself leads to over-treatment. Two asthma experts discuss factors for and against this proposition, identify issues on which more research is needed, and suggest areas in which guidelines can be changed in order to facilitate more appropriate prescribing of asthma medications. These strategies include better validation of the concepts underlying asthma treatment recommendations, stronger recommendations that every treatment change should be followed up with a scheduled review using evidence-based assessment tools and incorporation of phenotype-specific considerations into treatment recommendations. In addition, the process for development and dissemination of clinical practice guidelines should ensure that recommendations are easily understood, feasible to implement, and relevant to everyday asthma care and the needs and concerns of patients and clinicians.