Stepping Down from Seretide 50/250 1 Puff Twice Daily
If your asthma has been well controlled for at least 3 months on Seretide 50/250 (fluticasone/salmeterol 250/50 mcg) twice daily, step down to Seretide 50/100 (fluticasone/salmeterol 100/50 mcg) twice daily rather than switching to fluticasone alone. 1, 2
When to Consider Stepping Down
- Timing: Attempt step-down only after achieving well-controlled asthma for at least 3 consecutive months 1
- Control criteria (all must be met): 1
- Symptoms ≤2 days/week
- Nighttime awakenings ≤2 times/month
- No interference with normal activities
- Short-acting beta-agonist use ≤2 days/week (excluding pre-exercise use)
- FEV1 or peak flow >80% predicted
- 0-1 exacerbations requiring oral corticosteroids in the past year
Recommended Step-Down Strategy
Preferred approach: Reduce to Seretide 50/100 (fluticasone/salmeterol 100/50 mcg) twice daily 2, 3
This strategy maintains:
- The combination therapy (corticosteroid + long-acting beta-agonist)
- Superior asthma control compared to corticosteroid monotherapy
- Better lung function and fewer symptoms than switching to fluticasone alone 2
Evidence: A randomized trial demonstrated that patients stepped down to fluticasone/salmeterol 100/50 mcg twice daily maintained significantly better morning peak flow (12.9 L/min difference, p<0.001) and asthma control compared to those switched to fluticasone 250 mcg twice daily alone 2
Alternative Step-Down Option
If Seretide 50/100 twice daily is unavailable, you may reduce to Seretide 50/250 once daily in the evening, though this is less optimal: 4
- Provides adequate symptom control for many patients
- Does not maintain 24-hour lung function improvements as effectively as twice-daily dosing
- May be appropriate for patients with adherence challenges
What NOT to Do
Never discontinue the long-acting beta-agonist (salmeterol) and switch to fluticasone monotherapy at the same step - this results in inferior asthma control 2, 5
Never use salmeterol as monotherapy - LABAs should never be used without an inhaled corticosteroid due to FDA black box warnings regarding increased risk of severe exacerbations and asthma-related deaths 1
Monitoring After Step-Down
- Reassess within 2-6 weeks after stepping down 1
- Monitor for: 1
- Increased symptom frequency
- Increased rescue inhaler use (>2 days/week)
- Declining peak flow or FEV1
- Nighttime awakenings
- Activity limitations
If control deteriorates: Step back up to the previous dose (Seretide 50/250 twice daily) immediately 1
Before Stepping Down - Critical Checks
Verify these factors that can masquerade as poor control: 1
- Inhaler technique: Ensure proper use of the Diskus device
- Adherence: Confirm patient has been taking medication consistently
- Environmental triggers: Address ongoing allergen or irritant exposures
- Comorbidities: Treat rhinitis, GERD, or other conditions affecting asthma
Long-Term Management
- Continue monitoring every 1-6 months once stable on the lower dose 1
- Further step-down may be possible after another 3+ months of well-controlled asthma 1
- The goal is to identify the minimum medication necessary to maintain control 1
Common pitfall: Stepping down too aggressively or too quickly. The evidence strongly supports maintaining combination therapy at a lower dose rather than eliminating the LABA component entirely 2, 3, 5