Table 1.

Factors to consider in choosing “start low, step up” versus “hit hard, step down” and their application to COPD treatment

Factors to Consider	Favors Step-Up Approach	Favors Step-Down Approach	Application to COPD
Consequences of treatment failure	Treatment failures are minimally consequential	Treatment failures have severe or long-lasting health effects	Exacerbations have profound clinical implications for patients
Harms of more intensive treatment	More intensive treatment associated with harm	More intensive treatments have minimal harms	ICS use associated with increased risk of pneumonia
Cost	Less intensive treatment costs less	More intensive treatment has similar cost or shown to be cost-effective	Triple therapy more expensive, but no data on cost effectiveness
Patient preference	Patients prefer less intensive, simpler treatment	Demonstrated acceptability of more intensive treatment	No data, but expect less impact with single inhaler delivery
Maintenance decision-making	Reliable measures to indicate treatment failure and guide step-up	Reliable, clinically relevant measures to indicate disease stability and guide step-down	No robust markers to guide step-up or step-down

Definition of abbreviation: COPD = chronic obstructive pulmonary disease; ICS = inhaled corticosteroid.