Summary of findings for the main comparison. ICS dose reduction compared with no change in ICS dose (no concomitant LABA) for adults with asthma.

ICS dose reduction compared with no change in ICS dose (no concomitant LABA) for adults with asthma
Patient or population: adults with asthma Setting: primary care and specialist centres Intervention: ICS dose reduction Comparison: no change in ICS dose (no concomitant LABA)
Outcomes	Anticipated absolute effects* (95% CI)		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with no change in ICS dose (no concomitant LABA)	Risk with ICS dose reduction
Exacerbation requiring OCS Follow‐up: range 10 weeks to 12 weeks	8 per 1000	14 per 1000 (1 to 140)	OR 1.86 (0.16 to 21.09)	261 (2 RCTs)	⊕⊝⊝⊝ Very lowa	No clear benefit or harm of stepping down the dose of ICS (very low‐quality evidence)
Asthma control assessed by: Asthma Symptom Scale from: 0 (no symptoms) to 5 (severe symptoms) Follow‐up: 10 weeks	Mean asthma control score in the no change in ICS dose group was 1.79.	MD 0.22 lower (1.05 lower to 0.61 higher)	‐	150 (1 RCT)	⊕⊕⊝⊝ Lowb	No clear benefit or harm of stepping down the dose of ICS (low‐quality evidence)
All‐cause SAEs Follow‐up: mean 12 weeks	8 per 1000	9 per 1000 (2 to 45)	OR 1.24 (0.25 to 6.25)	742 (2 RCTs)	⊕⊕⊝⊝ Lowc	No clear benefit or harm of stepping down the dose of ICS (low‐quality evidence)
Steroid‐related AEs Follow‐up: range 10 weeks to 12 weeks	31 per 1000	23 per 1000 (5 to 100)	OR 0.76 (0.16 to 3.54)	261 (2 RCTs)	⊕⊝⊝⊝ Very lowd	No clear benefit or harm of stepping down the dose of ICS (very low‐quality evidence)
Health‐related quality of life (change from baseline) assessed by: AQLQ Follow‐up: 12 weeks	Mean change from baseline in health‐related quality of life for the no change in ICS dose group was 0.02.	MD 0.21 lower (0.33 lower to 0.09 lower)	‐	554 (1 RCT)	⊕⊝⊝⊝ Very lowe	No clear benefit or harm of stepping down the dose of ICS (very low‐quality evidence); MCID is 0.5 for AQLQ
Lung function, FEV1 (L) assessed by: spirometry Follow‐up: range 10 weeks to 12 weeks	Mean FEV1 in the no change in ICS dose group was 3.15 litres.	MD 0.02 litres lower (0.12 lower to 0.08 higher)	‐	261 (2 RCTs)	⊕⊕⊝⊝ Lowf	No clear benefit or harm of stepping down the dose of ICS (low‐quality evidence)
Exacerbations requiring hospitalisation ‐ not reported	‐	‐	‐	‐	‐	Outcome not reported by included studies
*Risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). aThe quality of the evidence was downgraded once for indirectness (included studies were performed at specialist centres) and twice for imprecision (no events reported by Magnussen 2000; confidence intervals include null effect and appreciable benefit or harm). bThe quality of the evidence was downgraded once for risk of bias (selective reporting) and once for indirectness (single study representative of one setting and drug regimen). cThe quality of the evidence was downgraded once for risk of bias (selective reporting) and once for imprecision (confidence intervals include null effect and appreciable benefit or harm). dThe quality of the evidence was downgraded once for risk of bias (selective reporting), once for indirectness (representative of specialist centres) and once for imprecision (confidence intervals include null effect and appreciable benefit or harm). eThe quality of the evidence was downgraded twice for risk of bias (selective reporting and lack of blinding (subjective outcome)) and once for indirectness (single study representative of one setting and drug regimen). fThe quality of the evidence was downgraded once for risk of bias (selective reporting) and once for imprecision (confidence intervals include null effect and appreciable benefit or harm). AE, adverse event; AQLQ, Asthma Quality of Life Questionnaire; CI, confidence interval; FEV1, forced expiratory volume in one second; GRADE, Grades of Recommendation, Assessment, Development and Evaluation; ICS, inhaled corticosteroid; LABA, long‐acting beta agonist; MCID, minimum clinically important difference; MD, mean difference; OCS, oral corticosteroid; OR, odds ratio; RCT, randomised controlled trial; RR, risk ratio; SAE, serious adverse event.
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to the estimate of effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.