Step-up therapy is the standard in personalizing an asthma treatment plan for your symptoms. Dosages will be stepped up or down until you and a doctor find the perfect balance.

Asthma is a chronic disease that currently doesn’t have a cure. The condition affects lung function, often making it difficult for people to breathe. While some people have ongoing chronic asthma, others may experience temporary flare-ups or attacks caused by exposure to specific triggers such as allergens or intense exercise.

The condition can be managed with a variety of treatments that minimize its interference with daily life. Keep reading to learn more about how the step-up approach helps doctors tailor your treatment to your needs.

Step-up therapy can be viewed as an essential way to manage asthma overall. Unlike other diseases that have cures, asthma treatment often revolves around controlling symptoms to prevent an asthma flare-up, or asthma attack, from occurring.

As with many other diseases, asthma exists on a spectrum. Some people may experience more severe asthma, in which symptoms pop up frequently, and need more medication to control them. Meanwhile, others may only experience asthma symptoms occasionally, such as with the onset of seasonal spring or fall allergies.

In either scenario, step-up therapy works by adjusting your medication dosage to complement the severity of your asthma at the time. During periods in which triggers are more frequent or if you’re still trying to get the condition under control, you may need a higher dose.

A doctor may increase the dose incrementally until you experience sustained periods without symptoms. If you have well-controlled asthma that’s exposed to a short-term trigger, a doctor may temporarily increase your dose until the triggering event ends.

Types of step-up therapy

Keep in mind that step-up therapy is broken into two subcategories. A doctor may use either or both of these strategies during your treatment.

  • Step-up short-term: A step-up short-term treatment includes temporary increase in dose because of an occasional flare-up for mild asthma. In most cases, the dose will be reduced within 3 to 10 days after your asthma stabilizes.
  • Step-up long-term: This treatment is used for more severe asthma, highlighted by persistent attacks. Step-down therapy won’t occur until the asthma symptoms stabilize for an extended observable period.

The asthma yardstick

Step-up treatment can vary widely based on age and the severity of your symptoms. In particular the American College of Allergy, Asthma, and Immunology outlines two measuring yardsticks, one for adults and another for children, which provide professional guidelines for carrying out step-up care.

  • The Pediatric Asthma Yardstick categorizes treatment across infants and children (ages 0 to 5 years), school-aged children (6 to 11 years), and adolescents (12 to 18 years).
  • The Adult Asthma Yardstick applies a 5-stage approach that’s spread between occasional flare-ups to those with frequent symptoms.

The priority for initiating step-up asthma therapy is to diagnose the severity of the condition. If step-up therapy is being considered for newly diagnosed asthma, several diagnostics may be required.

Along with taking a family history and detailing symptoms and severity, you may be asked to complete a lung function test or undergo a physical exam that looks at the skin on your chest as well as the upper respiratory tract.

Almost all step-up therapy follows the same six-step approach with recurrent reassessments every 2 to 6 weeks to either increase or reduce the medication regimen:

  1. Step one: Bronchodilators (short-acting beta-antagonists) or medications are prescribed to immediately open the airways. These are usually used on an as-needed basis.
  2. Step two: Low-dose inhaled steroids are also prescribed, but children ages 4 years and younger will need a referral.
  3. Step three: A combination of low dose inhaled steroids, bronchodilators, or medium-dose inhaled steroids will be prescribed for adults and children over the age of 12 years.
    • Children of ages 5 to 11 years may also be prescribed the above or an alternative consisting of a low dose inhaled steroid and leukotriene blocker.
    • Children 4 years of age and younger will usually be prescribed a medium dose of inhaled steroids.
  4. Step four: Children of age 5 and older will be prescribed a medium-dose inhaled steroid and a long-acting beta-antagonist. Meanwhile, children 4 years old and younger may shift to the medium-dose inhaled steroid and leukotriene blocker combination.
  5. Step five: Children 5 to 11 years and people over 12 years may be prescribed a high dose inhaled steroid and a long-acting beta-antagonist. Meanwhile, children 4 years and younger may begin a high dose inhaled steroid and combine it with either a long-acting beta-antagonist or a leukotriene blocker after consultation with an asthma specialist.
  6. Step six: Children 5 to 11 years usually maintain the same medication regimen from step five. However, people 12 years and older may also incorporate an oral steroid. Children 4 years of age and younger usually also maintain the step five regimen if recommended. Before upgrading to this treatment plan, a consultation with an asthma specialist is necessary.

The inverse: Step-down therapy

While asthma step-up therapy tends to get the most attention in asthma management, there’s an inverse treatment plan known as “step-down therapy.” Just like step-up therapy focuses on incremental dose increases that parallel symptom intensity, step-down does the reverse.

According to a 2012 review of studies, in most cases physicians will begin to incrementally lower your medication dose when symptoms begin to resolve, lung function improves, and especially when asthma becomes well-controlled.

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Assuming that you stick to your medication regimen and also attend ongoing follow-up appointments to monitor dosage and lung function, step-up therapy can work.

While these protocols have been in use for decades, even recent studies confirm that carefully increasing or decreasing the dose of asthma medications is the best way to control asthma symptoms.

If your asthma isn’t well-managed, you may consider asking a physician if using a graduated step-up approach makes sense. Often, asthma is poorly managed in people who experience barriers to care such as living in a “medical desert” (areas where people have inadequate access to healthcare or lack medical insurance).

A physician may be able to assist you with providing resources for lower-cost medications and even recommend generics to help reduce expenses.

The cost of step-up therapy can vary widely depending on your insurance provider and the included prescription coverage. In most instances, you can contact a provider for a specific breakdown of asthma medication costs and related fees for seeing an asthma specialist.

You may expect to spend more in the initial step-up therapy stages as you and a doctor work to get your asthma under control. As you progress, and especially if you begin stepping down, your cumulative prescription expenses and doctor’s copays may decline over time.

Medicaid and CHIP

If you or your child are on Medicaid or the Children’s Health Insurance Program (CHIP), both programs tend to cover all or almost all related medical expenses. Still, because coverage can vary by state, it’s important to contact the specific Medicaid insurer that’s authorized in your state.


Medicare is divided into several parts, and not all components apply to covering asthma costs. In particular, you’ll need the Medicare Part D plan, which is for prescription drug coverage.

You may still need to refer to your plan to confirm which specific medications are covered and if it requires generics versus name brands.

Drug assistance programs

If you’re unable to afford asthma medications, don’t have insurance, or your insurance doesn’t fully cover your required prescriptions, there’s another option. Many pharmaceutical firms, state advocacy groups, and even nonprofits provide grants and offer programs designed to assist in covering the cost of your prescriptions.

In many cases, the medications may be free or with a significantly lower copay. The Asthma and Allergy Foundation of America offers a list of available services for asthma medications divided by pharmaceutical companies and states that provide assistance.

Currently there’s no cure for asthma, but the chronic condition doesn’t have to interfere with your quality of life.

When well-managed, people with asthma can live full and engaged lives. Step-up therapy and its companion step-down therapy are two methods that physicians can use to help prevent asthma symptoms from sidelining you.