In what situation should the ICS dose not be decreased when stepping down therapy?

The correct answer is that the inhaled corticosteroid (ICS) dose should not be decreased when stepping down therapy for patients on ICS-LABA (long-acting beta-agonist) combinations with severe asthma. This population is typically treated with a more aggressive regimen due to the severity of their condition, and any reduction in dosage can risk loss of asthma control that is critical for maintaining their health and preventing exacerbations.

In patients with severe asthma, the underlying pathophysiology requires consistent and adequate suppression of inflammation, which ICS provides. Reducing the dose could result in insufficient control of airway inflammation and bronchoconstriction, leading to increased symptoms and potential exacerbations.

For the other situations: patients with mild asthma often tolerate reductions in ICS, as their asthma is generally more easily managed and they have lower overall inflammation. Those who have never had exacerbations or who use short-acting beta-agonists (SABA) infrequently are also likely more stable and can often handle reductions in ICS without a significant risk of exacerbation. Thus, in these cases, stepping down therapy may be appropriate. However, with patients who have severe asthma on combination therapy, maintaining the ICS dosage is crucial to ensure continued control of their disease.