How to Treat Kids' Hard-to-Control Asthma

Different Kids Do Best With Different "Step-Up" Treatments

By Daniel J. DeNoon
WebMD Health News

Reviewed by Laura J. Martin, MD

March 17, 2010 - What's the next step when a child's regular steroid inhaler fails to prevent asthma attacks? Different kids do best with different step-up treatments, a study funded by the National Institutes of Health (NIH) shows.

The drugs with the best chance of success -- 45% -- are long-acting beta-agonists (LABAs), the study suggests. But safety concerns limit the use of these agents, the best known of which are Serevent and Foradil and the combination products Advair and Symbicort.

About 30% of kids, the study found, do best either with a leukotriene-receptor antagonist (LTRA, brands include Accolate, Singulair, and Zyflo) or by doubling the dose of the child's current inhaled steroid medication.

"Nearly all the children had a differential response to each step-up therapy," found University of Wisconsin researcher Robert F. Lemanske Jr., MD, and colleagues.

Treating Tough Asthma

The study enrolled 182 children age 6 to 17 years. All had recent asthma attacks despite using a steroid inhaler twice a day.

For three 16-week periods, each child continued on his or her baseline dose of inhaled corticosteroid and tried a different step-up treatment -- a LABA (Advair), a LTRA (Singulair), or a double dose of their steroid inhaler (Flovent).

The bottom line: No clear winner. Moreover, there were few clues to predict which kids were most likely to do best on which step-up treatment. The few clues to emerge:

  • Hispanic and non-Hispanic white children were most likely to have the best response to LABA and least likely to have the best response to doubling inhaled steroid dosage.
  • Black children were equally likely to have the best response to LABA or doubling inhaled steroids and less likely to have the best response to LTRA.
  • Children who did not have eczema were most likely to have the best response to LABA.

But neither age, sex, year-long allergies, lung function, previous use or nonuse of inhaled steroids, number of days asthma was under control before step-up treatment, or number of recent asthma attacks predicted which step-up treatment would work best.

What Should Parents Do?

Advice to parents and doctors comes in an editorial by Erika von Mutius, MD, of University Children's Hospital, Munich; and Jeffrey M. Drazen, MD, editor of the New England Journal of Medicine.

Von Mutius and Drazen argue that the choice of step-up therapy should be based first on safety, second on price, and third on convenience.

"Since we still have lingering concerns about the safety of LABAs in the treatment of asthma, in that they may promote severe exacerbations or fatal asthmatic events ... our first choice would be either increasing the dose of an inhaled corticosteroid or adding an LTRA to the therapeutic regimen," they suggest.

But whichever treatment a child's parent and doctor choose, von Mutius and Drazen stress the need for the doctor to stay in close touch with the child to make sure the chosen treatment truly works.

"For the patient whose asthma is hard to control, there is simply no substitute for attentive individual follow-up," they insist.

The Lemanske study and the von Mutius editorial appear in the March 18 issue of the New England Journal of Medicine.

The Lamanske study was funded by a grant from the NIH-sponsored Childhood Asthma Research and Education (CARE) Network. Study medications were donated by GlaxoSmithKline and Merck. Several of the study authors declare receiving consulting fees, lecture fees, and/or grants from various drug companies that make asthma medications. Von Mutius and Drazen declare no such interests.


Asthma is a chronic respiratory disease. See Answer

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Lemanske, R.F. New England Journal of Medicine, March 18, 2010; vol 362: pp 975-985.
Von Mutius, E. and Drazen, J.M. New England Journal of Medicine, March 18, 2010; vol 362: pp 1042-1043.
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