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Zhang L, Fu Z, Deng H, Xie Q, Wu W. Identification and treatment of persistent small airway dysfunction in paediatric patients with asthma: a retrospective cohort study. BMC Pulm Med 2024; 24:94. [PMID: 38395894 PMCID: PMC10893734 DOI: 10.1186/s12890-024-02907-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Asthma is a common respiratory disease. In asthma, the small airways have more intensive inflammation and prominent airway remodelling, compared to the central airways. We aimed to investigate the predictive value of risk factors and the fractional concentration of exhaled nitric oxide (FeNO) for persistent small airway dysfunction (p-SAD), and compare the effects of different treatment modalities. METHODS This retrospective cohort study included 248 children with asthma (aged 4-11 years). Binary logistic regression was used to analyse the risk factors for p-SAD. Correlations among FEV1/FVC, small airway function parameters, and FeNO levels in patients with asthma were analysed using Spearman's rank correlation. The receiver operating characteristic curve and the Delong test were used to analyse the predictive value of FeNO for p-SAD. Differences in the treatment effects of inhaled corticosteroids (ICS) and ICS with a long-acting beta-agonist (ICS/LABA) on p-SAD were analysed using Fisher's exact test. RESULTS Asthmatic children with older age of receiving the regular treatment (OR 1.782, 95% CI 1.082-2.935), with younger age at the time of onset of suspected asthma symptoms (OR 0.602, 95% CI 0.365-0.993), with longer duration of using ICS or ICS/LABA (OR 1.642, 95% CI 1.170-2.305) and with worse asthma control (OR 3.893, 95% CI 1.699-8.922) had increased risk for p-SAD. Significant negative correlations of small airway function parameters with FeNO at a 200 mL/s flow rate (FeNO200), and the concentration of nitric oxide in the alveolar or acinar region (CaNO) were observed. The areas under the curve of FeNO200 (cut-off:10.5ppb), CaNO (cut-off:5.1ppb), and FeNO200 combined with CaNO were 0.743, 0.697, and 0.750, respectively, for asthma with p-SAD. After using ICS or ICS/LABA, switching to ICS/LABA was easier than continuing with ICS to improve small airway dysfunction (SAD) in the 8th month. CONCLUSIONS Paediatric asthma with p-SAD is associated with older age at receiving regular treatment, younger age at the time of onset of suspected asthma symptoms, longer duration of using ICS or ICS/LABA, worse asthma control, and higher FeNO200 and CaNO levels, all of which can be combined with small airway function indicators to distinguish p-SAD from asthma. ICS/LABA improves SAD better than ICS alone.
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Affiliation(s)
- Lulu Zhang
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, NO.136, Zhongshan Second Road, 400014, Chongqing, China
| | - Zhou Fu
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, NO.136, Zhongshan Second Road, 400014, Chongqing, China
| | - Hua Deng
- Department of Pediatric Internal Medicine, Chongqing Youyoubaobei Women and Children's Hospital, NO.999, Jiarong Road, 401122, Chongqing, China
| | - Qin Xie
- Department of Pediatric Internal Medicine, Chongqing Youyoubaobei Women and Children's Hospital, NO.999, Jiarong Road, 401122, Chongqing, China
| | - Wenjie Wu
- Department of Pediatric Internal Medicine, Chongqing Youyoubaobei Women and Children's Hospital, NO.999, Jiarong Road, 401122, Chongqing, China.
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Urbani F, Cometa M, Martelli C, Santoli F, Rana R, Ursitti A, Bonato M, Baraldo S, Contoli M, Papi A. Update on virus-induced asthma exacerbations. Expert Rev Clin Immunol 2023; 19:1259-1272. [PMID: 37470413 DOI: 10.1080/1744666x.2023.2239504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/01/2023] [Accepted: 07/18/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Viral infections are common triggers for asthma exacerbation. Subjects with asthma are more susceptible to viral infections and develop more severe or long-lasting lower respiratory tract symptoms than healthy individuals owing to impaired immune responses. Of the many viruses associated with asthma exacerbation, rhinovirus (RV) is the most frequently identified virus in both adults and children. AREAS COVERED We reviewed epidemiological and clinical links and mechanistic studies on virus-associated asthma exacerbations. We included sections on severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), the latest evidence of coronavirus disease 2019 (COVID-19) in asthma patients, and past and future searches for therapeutic and prevention targets. EXPERT OPINION Early treatment or prevention of viral infections might significantly reduce the rate of asthma exacerbation, which is one of the key points of disease management. Although it is hypothetically possible nowadays to interfere with every step of the infectious cycle of respiratory tract viruses, vaccination development has provided some of the most encouraging results. Future research should proceed toward the development of a wider spectrum of vaccines to achieve a better quality of life for patients with asthma and to reduce the economic burden on the healthcare system.
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Affiliation(s)
- Francesca Urbani
- Department of Translational Medicine, University of Ferrara Medical School, University of Ferrara, Sant'anna University Hospital, Ferrara, Italy
| | - Marianna Cometa
- Department of Translational Medicine, University of Ferrara Medical School, University of Ferrara, Sant'anna University Hospital, Ferrara, Italy
| | - Chiara Martelli
- Department of Translational Medicine, University of Ferrara Medical School, University of Ferrara, Sant'anna University Hospital, Ferrara, Italy
| | - Federica Santoli
- Department of Translational Medicine, University of Ferrara Medical School, University of Ferrara, Sant'anna University Hospital, Ferrara, Italy
| | - Roberto Rana
- Department of Translational Medicine, University of Ferrara Medical School, University of Ferrara, Sant'anna University Hospital, Ferrara, Italy
| | - Antonio Ursitti
- Department of Translational Medicine, University of Ferrara Medical School, University of Ferrara, Sant'anna University Hospital, Ferrara, Italy
| | - Matteo Bonato
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Simonetta Baraldo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Marco Contoli
- Department of Translational Medicine, University of Ferrara Medical School, University of Ferrara, Sant'anna University Hospital, Ferrara, Italy
| | - Alberto Papi
- Department of Translational Medicine, University of Ferrara Medical School, University of Ferrara, Sant'anna University Hospital, Ferrara, Italy
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3
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Chang AB, Oppenheimer JJ, Dunlap W, Lieberman JA, Irwin RS. Yardstick for managing cough. Part 2: in children. Ann Allergy Asthma Immunol 2023; 130:681-689. [PMID: 36736723 DOI: 10.1016/j.anai.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 02/04/2023]
Abstract
Nationwide statistics in the United States and Australia reveal that cough of undifferentiated duration is the most common complaint for which patients of all ages seek medical care in the ambulatory setting. Management of chronic cough is one of the most common reasons for new patient visits to respiratory specialists. Because symptomatic cough is such a common problem and so much has been learned about how to diagnose and treat cough of all durations but especially chronic cough, this 2-part yardstick has been written to review in a practical way the evidence-based guidelines most of which have been developed from high-quality systematic reviews on how best to manage cough of all durations in adults, adolescents, and children. Chronic cough in children is often benign and self-limiting. Using established and validated protocols and specific pointers (clues in history, findings on examination) can aid the clinician in identifying causes when present and improve outcomes. In this manuscript, part 2 of the 2-part series, we provide evidence-based, expert opinion recommendations on the management of chronic cough in the pediatric patient (<14 years of age).
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Affiliation(s)
- Anne B Chang
- Australian Centre for Health Services Innovation, Queensland's University of Technology, and Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia; Menzies School of Health Research, Darwin, Australia.
| | | | - Whitney Dunlap
- Department of Medicine, UMass Chan Medical School, Worcester, Massachusetts; Northeast Allergy, Asthma, and Immunology, Worcester, Massachusetts
| | - Jay Adam Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Richard S Irwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, UMass Memorial Medical Center, Worcester, Massachusetts
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4
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Shen BH, Aoyama B, Lee B. Inpatient albuterol spacing as an indicator of discharge readiness. J Asthma 2023; 60:57-62. [PMID: 34978948 DOI: 10.1080/02770903.2021.2025390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION In children admitted for asthma exacerbation, multiple evidence-based, clinical practice guidelines exist to identify readiness for discharge. At many institutions, weaning of albuterol is part of the discharge process, though presently there is limited evidence to guide best practice. We sought to determine how many children required escalation of care once placed on every 4-h dosing of albuterol. METHODS We performed a consecutive case series of pediatric patients between 5 and 18 years of age admitted to a single tertiary care center's pediatric hospitalist service between April 2015 and April 2018 with a discharge diagnosis of asthma. Patients admitted to the intensive care unit (PICU) or a subspecialty service were excluded, as has been done previously. Time between albuterol administrations was tracked. "Treatment escalation" was defined as when a patient required more frequent albuterol more dosing after previously tolerating albuterol doses separated by more than 3.5 h. RESULTS A total of 331 patients met inclusion criteria; 136 were female (41.1%), and the average age was 8.8 years. Twenty-six of the 331 patients (7.8%) required escalation of albuterol therapy. Eleven patients returned to the emergency department (ED) following discharge, 2 of which had experienced treatment escalation while admitted. CONCLUSIONS Our case series showed that most patients were safe to discharge after spacing albuterol treatments to 4 h, with few returns to the ED and readmissions. Albuterol spacing to every 4 h once appears to be a reasonable discharge criterion, but future studies are needed to determine if this is a safe and efficient.
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Affiliation(s)
- Burton H Shen
- Department of Pediatrics, Hasbro Children's Hospital, Providence, RI, USA.,Brown University, Providence, RI, USA
| | - Brianna Aoyama
- Department of Pediatric Pulmonlogy, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Brian Lee
- Department of Pediatric Emergency Medicine, Children's National Hospital, Washington, DC, USA
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Calcaterra V, Nappi RE, Farolfi A, Tiranini L, Rossi V, Regalbuto C, Zuccotti G. Perimenstrual Asthma in Adolescents: A Shared Condition in Pediatric and Gynecological Endocrinology. CHILDREN 2022; 9:children9020233. [PMID: 35204953 PMCID: PMC8870409 DOI: 10.3390/children9020233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 12/12/2022]
Abstract
Asthma is a frequent medical condition in adolescence. The worsening of the most common symptoms perimenstrually is defined as perimenstrual asthma (PMA). The cause of PMA remains unclear, but a role for hormonal milieu is plausible. Data on PMA in adolescents are limited, and its management is not fully established. We aimed to discuss the PMA phenomenon in young females from pathophysiology to preventive strategies, focusing on the relationship with the hormonal pattern. The fluctuation of estrogens at ovulation and before menstruation and the progesterone secretion during the luteal phase and its subsequent withdrawal seem to be the culprits, because the deterioration of asthma is cyclical during the luteal phase and/or during the first days of the menstrual cycle. Conventional asthma therapies are not always effective for PMA. Preventive strategies may include innovative hormonal contraception. Even a possible beneficial effect of other hormonal treatments, including estrogens, progestogens, and androgens, as well as leukotriene receptor antagonists and explorative approach using microbial-directed therapy, is considered. The underlying mechanisms, through which sex-hormone fluctuations influence asthma symptoms, represent a challenge in the clinical management of such a distressing condition. Further studies focused on young females are mandatory to promote adolescent health.
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Affiliation(s)
- Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy
- Department of Pediatrics, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy; (A.F.); (V.R.); (G.Z.)
- Correspondence:
| | - Rossella Elena Nappi
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (R.E.N.); (L.T.)
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Andrea Farolfi
- Department of Pediatrics, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy; (A.F.); (V.R.); (G.Z.)
| | - Lara Tiranini
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (R.E.N.); (L.T.)
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Virginia Rossi
- Department of Pediatrics, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy; (A.F.); (V.R.); (G.Z.)
| | - Corrado Regalbuto
- Pediatric Unit, Fondazione IRCCS Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy;
| | - Gianvincenzo Zuccotti
- Department of Pediatrics, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy; (A.F.); (V.R.); (G.Z.)
- Department of Biomedical and Clinical Science “L. Sacco”, University of Milano, 20157 Milano, Italy
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Abstract
An estimated 7 million children in the United States have asthma, which causes a significant health care burden and affects quality of life. The minority of these children have asthma that does not respond to Global Initiative for Asthma steps 4 and 5 care, and biological medications are recommended at this level in the 2019 Global Initiative for Asthma recommendations. In addition, biologics have been introduced into the care of children with allergic skin diseases. Omalizumab and mepolizumab are approved for children as young as 6 years, and benralizumab and dupilumab are approved for people aged ≥12 years. Reslizumab is approved only for people aged ≥18 years. These monoclonal antibodies may be added for appropriate patients when asthma or allergic skin diseases are not well controlled. Pediatricians and pediatric subspecialists should work together and be aware of the benefits and risks of these medications for their patients, as well as the practical implications of providing these options for their patients. This clinical report serves as an evaluation of the current literature on these types of medications in the treatment of children with asthma and allergic skin disease.
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Affiliation(s)
- Heather Hoch De Keyser
- Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, School of Medicine, University of Colorado Anschutz, Breathing Institute at Children's Hospital Colorado, Denver, Colorado
| | - Bradley Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California
| | - Chitra Dinakar
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
- Deceased
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7
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Averell CM, Laliberté F, Germain G, Slade DJ, Duh MS, Spahn J. Disease burden and treatment adherence among children and adolescent patients with asthma. J Asthma 2021; 59:1687-1696. [PMID: 34346263 DOI: 10.1080/02770903.2021.1955377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To assess asthma burden and medication adherence in a US de-identified patient level claims database. METHODS This retrospective observational study used the IQVIA PHARMETRICS PLUS database to identify patients aged 5-17 years, diagnosed with asthma between 01/01/2012-09/30/2017 (asthma cohort), and those initiating treatment with twice-daily inhaled corticosteroids (ICS) or twice-daily ICS/long-acting beta2 agonists (LABA) (treatment cohorts; index date = first dispensing). Patient characteristics, asthma medication, and healthcare resource utilization were assessed over a 12-month baseline period. Treatment cohort endpoints were assessed in a 12-month follow-up period, including: adherence using proportion of days covered (PDC); persistence (no gap >45 days between dispensings). RESULTS The asthma cohort included 186,868 patients (112,689 children, mean age 7.9 years; 74,179 adolescents, mean age 14.3 years). During baseline, 34.5% used ICS or ICS/LABA, 24% used oral corticosteroids, 11.1% had ≥1 asthma-related emergency department visit, 2.2% had ≥1 asthma-related hospitalization. Among treatment cohorts, 47,276 and 10,247 patients initiated twice-daily ICS and ICS/LABA, respectively (mean ages: 9.9; 12.5 years). Mean PDC adherence to twice-daily ICS and ICS/LABA was 30% and 34% at 6 months (PDC ≥0.8: 4.3%; 6.1%); 21% and 24% at 12 months (PDC ≥0.8: 1.8%; 2.8%). Persistence with twice-daily ICS and ICS/LABA was 10.1% and 14.2% at 6 months; 5.6% and 8.0% at 12 months. CONCLUSIONS A large disease burden and unmet need exist among US children/adolescent asthma patients, evidenced by low use of, and poor adherence to, ICS-containing medication, the notable proportion of oral corticosteroid users, and higher-than-expected asthma-related emergency department and hospitalization rates.
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Affiliation(s)
| | | | | | - David J Slade
- GlaxoSmithKline plc., Research Triangle Park, NC, USA
| | - Mei S Duh
- Analysis Group, Inc., Boston, MA, USA
| | - Joseph Spahn
- GlaxoSmithKline plc., Research Triangle Park, NC, USA
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Abellard A, Pappalardo AA. Overview of severe asthma, with emphasis on pediatric patients: a review for practitioners. J Investig Med 2021; 69:1297-1309. [PMID: 34168068 DOI: 10.1136/jim-2020-001752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/03/2022]
Abstract
Asthma is the most common life-threatening chronic disease in children. Although guidelines exist for the diagnosis and treatment of asthma, treatment of severe, pediatric asthma remains difficult. Limited studies in the pediatric population on new asthma therapies, complex issues with adolescence and adherence, health disparities, and unequal access to guideline-based care complicate the care of children with severe, persistent asthma. The purpose of this review is to provide an overview of asthma, including asthma subtypes, comorbidities, and risk factors, to discuss diagnostic considerations and pitfalls and existing treatments, and then present existing and emerging therapeutic approaches to asthma management. An improved understanding of asthma heterogeneity, clinical characteristics, inflammatory patterns, and pathobiology can help further guide the management of severe asthma in children. More studies are needed in the pediatric population to understand emerging therapeutics application in children. Effective multimodal strategies tailored to individual characteristics and a commitment to address risk factors, modifiers, and health disparities may help reduce the burden of asthma in the USA.
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Affiliation(s)
- Arabelle Abellard
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Andrea A Pappalardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA .,Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
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9
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Tosca MA, Pistorio A, Silvestri M, Marseglia GL, Ciprandi G. The comparison between children and adolescents with asthma provided by the real-world "ControL'Asma" study. J Asthma 2021; 59:1531-1536. [PMID: 34112042 DOI: 10.1080/02770903.2021.1941089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Because asthma is a disease that changes over time, the Italian Society of Pediatric Allergy and Immunology launched a nationwide study on asthma control (the ControL'Asma study). The intent was to test the hypothesis that children with asthma could present a different pattern compared to adolescents. In the study, we compared children with adolescents in a real-world setting by analyzing the asthma control grade and other asthma-related parameters. METHODS This cross-sectional real-world study included 471 asthmatic children (<age 12) and adolescents (≥age 12), mostly male (n = 326; 69.2%), who were consecutively enrolled at 10 tertiary pediatric allergy clinics. Asthma control level was evaluated according to the Global Initiative for Asthma (GINA) guidelines, the Childhood Asthma Control Test (cACT) questionnaire for children, and the Asthma Control Test (ACT) questionnaire for adolescents, history, rhinitis comorbidity, allergy, clinical examination, lung function, and perception of asthma symptoms assessed by visual analogue scale (VAS). RESULTS There was no difference between the age groups in asthma control as determined by both GINA criteria and the cACT/ACT questionnaires. However, adolescents with asthma had significantly more frequent rhinitis comorbidity (p = 0.02; OR = 2.07) and allergy (p = 0.012; OR = 3.72) than children. Asthma severity, lung function, and symptom perception were not different between age groups. CONCLUSIONS The current study showed that asthma control is not associated with age in young people. Adolescents with asthma did experience rhinitis and allergy more frequently than children. These findings reflect the progressive nature of the allergic phenotype in young patients.
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Affiliation(s)
- Maria Angela Tosca
- Allergy Center, Department of Pediatrics, Istituto Giannina Gaslini, Genoa, Italy
| | - Angela Pistorio
- Epidemiology, Biostatistics and Committe, Department of Direction, Istituto Giannina Gaslini, Genoa, Italy
| | - Michela Silvestri
- Allergy Center, Department of Pediatrics, Istituto Giannina Gaslini, Genoa, Italy
| | - Gian Luigi Marseglia
- Pediatrics Clinic, Pediatrics Department, Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Giorgio Ciprandi
- Allergy Clinic, Department of Outpatients, Casa di Cura Villa Montallegro, Genoa, Italy
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Rodriguez-Martinez CE, Sossa-Briceño MP. Are we overcoming our inability to have pediatric patients properly use inhaled corticosteroids by inappropriately escalating their therapy? J Asthma 2021; 59:1360-1371. [PMID: 34044743 DOI: 10.1080/02770903.2021.1936016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To perform a narrative review to describe and discuss potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients. DATA SOURCES Articles available in electronic databases, published from inception to April 2021. STUDY SELECTIONS Relevant articles in the literature that discuss and analyze potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients. RESULTS Validated self-reported questionnaires, weighing inhaler canisters, and pharmacy records might be the most suitable methods for assessing adherence to inhaled controller therapy in clinical practice. Additionally, validated instruments could be used as an objective measurement of the adequacy of inhaler technique. Finally, empathy and a true and strong physician-parent/patient partnership have a more powerful influence on adherence than almost any other factor, and they are probably the most cost-effective methods not only for detecting poor adherence to controller therapy but also for dealing with and improving it. CONCLUSIONS Failure to detect or effectively handle nonadherence and/or inhaler misuse in a patient with uncontrolled asthma can mislead clinicians into thinking that the patient is nonresponsive to the original less-intensive therapy, resulting in unneeded dosage increases and/or escalation of controller therapy to more costly medications, in some cases reaching the level of biologic therapy.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
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Cazzola M, Matera MG, Rogliani P, Calzetta L, Ora J. Step-up and step-down approaches in the treatment of asthma. Expert Rev Respir Med 2021; 15:1159-1168. [PMID: 34032534 DOI: 10.1080/17476348.2021.1935245] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Significant intraindividual and temporal variability in symptom control is a feature of asthma that requires careful monitoring and the need to periodically review and adjust therapy. Both NHLBI/NAEPP and GINA offer helpful algorithms for a stepping approach to asthma.Areas covered: The problems arisen in applying the stepwise approach to the treatment of asthma proposed by NHLBI/NAEPP and GINA algorithms and their possible alternatives.Expert opinion: The current therapeutic stepping approach to asthma, which takes into account lung function, symptoms and quality of life, is certainly useful, but it does not consider the underlying mechanisms. Furthermore, patient's overestimation or underestimation of the severity of the disease and differences in the opinions on the level of asthma control required between patients and physicians and also between physicians in both primary care and specialist settings are common and may negatively affect asthma control and future risks. A reassessment of the conventional stepping approach to management of asthma is now needed. A pragmatic approach that sets therapeutic goals for each individual and associates them with the treatable traits of asthma which, when therapeutically targeted, will in many cases help to achieve the goals, seems more reasonable than the present stepping approach.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.,Division of Respiratory Medicine, University Hospital "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital "Tor Vergata", Rome, Italy
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Alharbi AS, Yousef AA, Alharbi SA, Al-Shamrani A, Alqwaiee MM, Almeziny M, Said YS, Alshehri SA, Alotaibi FN, Mosalli R, Alawam KA, Alsaadi MM. Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus. Ann Thorac Med 2021; 16:188-218. [PMID: 34012486 PMCID: PMC8109687 DOI: 10.4103/atm.atm_74_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022] Open
Abstract
The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.
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Affiliation(s)
- Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahd Hospital of the University, Khobar, Saudi Arabia
| | - Saleh A. Alharbi
- Department of Pediatrics, Umm Al-Qura University, Mecca, Saudi Arabia
- Department of Pediatrics, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mansour M. Alqwaiee
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mohammed Almeziny
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Yazan S. Said
- Department of Pediatrics, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Saleh Ali Alshehri
- Department of Emergency, Pediatric Emergency Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Faisal N. Alotaibi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Rafat Mosalli
- Department of Pediatrics, Umm Al Qura University, Makkah, Saudi Arabia
- Department of Pediatrics, International Medical Center, Jeddah, Saudi Arabia
| | - Khaled Ali Alawam
- Department of Respiratory Therapy Sciences, Inaya Medical College, Riyadh, Saudi Arabia
| | - Muslim M. Alsaadi
- Department of Pediatrics, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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13
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Leung DYM. Origins of allergy: Scratching below the surface. Ann Allergy Asthma Immunol 2020; 125:497-498. [PMID: 33097164 DOI: 10.1016/j.anai.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Donald Y M Leung
- Department of Pediatrics, National Jewish Health, Denver, Colorado.
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14
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Hopp RJ, Wilson MC, Pasha MA. Small Airway Disease in Pediatric Asthma: the Who, What, When, Where, Why, and How to Remediate. A Review and Commentary. Clin Rev Allergy Immunol 2020; 62:145-159. [PMID: 33241492 DOI: 10.1007/s12016-020-08818-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 12/18/2022]
Abstract
Asthma affects all portions of the airways. Small airways, however, comprise a substantial component of the conducting lung air flow. In asthma, inflammatory processes can affect the whole respiratory tract, from central to peripheral/small airways. The emphasis in adult and pediatric respiratory disease clinics is to focus on large airway obstruction and reversibility. This information, although valuable, underemphasizes a large portion of the conduction airway of asthmatics. Standard descriptions of asthma management focus on a multiple medication approaches. We particularly focused on the management of asthma in the international guidelines for the Global Initiative for Asthma (GINA). Overall, however, minimal attention is placed on the small airway pool in asthma medical management. We took the opportunity to thoroughly review and present specific data from the adult asthma literature which supported the concept that small airway abnormalities may play a role in the pathogenesis and clinical expression of asthma. Based on the conclusions of the adult asthma literature, we here present a thorough review of the literature as it relates to small airway disease in children with asthma. We used, collectively, individual data sources of data to expand the information available from standard diagnostic techniques, especially spirometry, in the evaluation of small airway disease. As the pharmacological approaches to moderate to severe asthma are advancing rapidly into the realm of biologics, we sought to present potential pharmacological options for small airway dysfunction in pediatrics prior to biological modifier intervention.
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Affiliation(s)
- Russell J Hopp
- Department of Pediatrics, University of Nebraska Medical Center and Children's Hospital and Medical Center, Omaha, NE, 68114, USA.
| | - Mark C Wilson
- Department of Pediatrics, University of Nebraska Medical Center and Children's Hospital and Medical Center, Omaha, NE, 68114, USA
| | - M Asghar Pasha
- Division of Allergy and Immunology, Albany Medical College, 176 Washington Avenue Extension, Suite 102, Albany, NY, 12203, USA
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15
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Licari A, Ciprandi G, Marseglia GL, Silvestri M, Tosca MA, Anastasio E, Brambilla I, Caffarelli C, Castagnoli R, Chini L, Ciprandi R, De Vittori V, Duse M, Di Cicco ME, Indinnimeo L, Kantar A, Leone M, Marinelli G, Moschese V, Olcese R, Peroni DG, Pistorio A, Salmaso C, Zicari AM. Asthma in children and adolescents: the ControL'Asma project. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020002. [PMID: 33004772 PMCID: PMC8023065 DOI: 10.23750/abm.v91i11-s.10295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 11/23/2022]
Abstract
The control of asthma is the objective of asthma management. However, it is difficult to obtain in clinical practice. The Italian Society of Allergy and Clinical Immunology promoted the nationwide project "ControL'Asma" to investigate the real situation in a group of children and adolescents with asthma. The preliminary outcomes demonstrated that many asthmatic subjects do not achieve adequate asthma control. Moreover, asthma in Italian children and adolescents was usually more frequent in males, had an early onset and allergic phenotype with very frequent rhinitis comorbidity, uncontrolled and partly controlled asthma affected about the half of subjects. However, this project suggested that the assessment of asthma symptom perception by VAS could be a reliable tool in the asthma management.
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Affiliation(s)
- Amelia Licari
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Giorgio Ciprandi
- Department of Medicine, Allergy Clinic, Casa di Cura Villa Montallegro, Genoa, Italy.
| | - Gian Luigi Marseglia
- Pediatric Clinic Department of Pediatrics, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy.
| | | | | | - Elisa Anastasio
- Department of Medical and Surgical Sciences, Pediatrics Unit, University"Magna Graecia", Catanzaro, Italy; “ControL’Asma” Study Group.
| | - Ilaria Brambilla
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy; “ControL’Asma” Study Group.
| | - Carlo Caffarelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy; “ControL’Asma” Study Group.
| | - Riccardo Castagnoli
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy; “ControL’Asma” Study Group.
| | - Loredana Chini
- Paediatric Immunopathology and Allergology Unit, Tor Vergata University Hospital, University of Roma Tor Vergata, Rome, Italy; “ControL’Asma” Study Group.
| | - Riccardo Ciprandi
- Cystic Fibrosis Center, IRCCS Istituto Giannina Gaslini-Ospedale Pediatrico, Genoa, Italy; “ControL’Asma” Study Group.
| | - Valentina De Vittori
- Department of Pediatrics, Sapienza University of Rome, Rome, Italy; “ControL’Asma” Study Group.
| | - Marzia Duse
- Department of Pediatrics, Sapienza University of Rome, Rome, Italy; “ControL’Asma” Study Group.
| | - Maria Elisa Di Cicco
- Pediatric Division, Department of Obstetrics, Gynecology and Pediatrics, St. Chiara University Hospital, Pisa, Italy; “ControL’Asma” Study Group.
| | - Luciana Indinnimeo
- Department of Pediatrics and NPI, University of Roma Sapienza, Rome, Italy; “ControL’Asma” Study Group.
| | - Ahmad Kantar
- Pediatric Cough and Asthma Center, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy; “ControL’Asma” Study Group.
| | - Maddalena Leone
- Maternal and Infantile Department of Pediatrics ASST Grande Ospedale Metropolitano Niguarda Milano, Italy; “ControL’Asma” Study Group.
| | - Guido Marinelli
- Pediatria, Università di Genova; “ControL’Asma” Study Group.
| | - Viviana Moschese
- Pediatric Allergology and Immunology Unit, University of Rome Tor Vergata, Policlinico Tor Vergata, Rome, Italy; “ControL’Asma” Study Group.
| | - Roberta Olcese
- Pediatric Allergy Center, Istituto Giannina Gaslini, Genoa, Italy; “ControL’Asma” Study Group.
| | - Diego G Peroni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy; “ControL’Asma” Study Group.
| | - Angela Pistorio
- IRCCS Istituto Giannina Gaslini, Genoa, Italy; “ControL’Asma” Study Group.
| | - Claudia Salmaso
- Pediatric Allergy Center, Istituto Giannina Gaslini, Genoa, Italy; “ControL’Asma” Study Group.
| | - Anna Maria Zicari
- Department of Pediatrics, Policlinico Umberto I, Sapienza University, Rome, Italy; “ControL’Asma” Study Group.
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16
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Humbert M, Bourdin A, Papadopoulos NG, Holgate ST, Hanania NA, Halpin DMG, Chapman KR, Gavornikova M, Price DB, Kaplan A, Heaney LG. Reducing the hidden burden of severe asthma: recognition and referrals from primary practice. J Asthma 2020; 58:849-854. [PMID: 32347748 DOI: 10.1080/02770903.2020.1759084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Since their introduction many decades ago, systemic corticosteroids have become a mainstay treatment for asthma. Despite being a highly effective therapy, corticosteroids can cause significant adverse effects in patients. This results in a "double hit" for some patients as they suffer the burden of disease as well as the burden of treatment-induced morbidity.This article aims to raise awareness of the potential, harmful side effects of prolonged or repeated exposure to systemic corticosteroids in asthma. It also highlights the importance of referral of the appropriate patients with asthma from primary care for specialist assessment once other considerations such as adherence, inhaler technique and co-morbidity have been evaluated. We propose a simple decision step that may help busy primary care physicians and general practitioners to identify patients who could benefit from specialist assessment.Our decision step suggests that a patient with asthma should be reviewed at least once by an asthma specialist if he/she (i) has received ≥2 courses of oral corticosteroids in the previous year; asthma remains uncontrolled despite good adherence and inhaler technique; or (ii) has attended an emergency department or was hospitalized for asthma care.Such referral could facilitate wider access to diagnostic tools, in-depth assessment of confounding comorbidities, and non-corticosteroid-based therapies as needed, which may be unavailable in primary practice.
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Affiliation(s)
- Marc Humbert
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicetre, France.,Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Arnaud Bourdin
- Department of Respiratory Diseases, Université de Montpellier, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Montpellier, France
| | - Nikolaos G Papadopoulos
- Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK.,The Allergy Department, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Nicola A Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Kenneth R Chapman
- Asthma and Airway Centre, University Health Network, and University of Toronto, Toronto, Ontario, Canada
| | | | - David B Price
- Observational and Pragmatic Research Institute, Singapore.,University of Aberdeen, Aberdeen, UK
| | - Alan Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada
| | - Liam G Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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17
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Chipps B, Taylor B, Bayer V, Shaikh A, Mosnaim G, Trevor J, Rogers S, Del Aguila M, Paek D, Wechsler ME. Relative efficacy and safety of inhaled corticosteroids in patients with asthma: Systematic review and network meta-analysis. Ann Allergy Asthma Immunol 2020; 125:163-170.e3. [PMID: 32302768 DOI: 10.1016/j.anai.2020.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/06/2020] [Accepted: 04/06/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Inhaled corticosteroids (ICSs) are recommended as first-line controller medications for persistent asthma. However, guidelines on the initial ICS doses, step-up and step-down algorithms, and when to switch to combination therapy vary. OBJECTIVE To understand the ideal starting doses of ICS therapy based on current evidence and to systematically compare low, moderate, and high starting doses of ICSs as monotherapy and in combination with long-acting β-agonists with respect to efficacy and safety. METHODS MEDLINE, Embase, and Cochrane databases were searched for relevant English-language articles published from 1980 to November 17, 2018. Randomized controlled trials with adult, steroid-naive, ICS-free (for ≥4 weeks) patients with asthma and a duration of 4 weeks or longer with an ICS treatment arm (monotherapy or combination therapy) were included. Separate fixed-effects Bayesian network meta-analyses were conducted on the extracted data for peak expiratory flow, forced expiratory volume in 1 second, nighttime rescue medication use, nighttime symptom score, and study withdrawal because of an adverse event. RESULTS A total of 31 randomized controlled trials were analyzed. All starting doses of ICSs were comparable with respect to nighttime rescue medication use, nighttime symptom score, change in forced expiratory volume in 1 second, and study withdrawal because of an adverse event. Significant improvement in morning peak expiratory flow was observed with high-dose ICSs and with low- and moderate-dose ICSs and long-acting β-agonists than with low-dose ICSs. CONCLUSION Overall, a high starting dose of ICSs had no additional clinical benefit in 3 of the 4 efficacy parameters compared with low or moderate ICS doses for controlling moderate to severe asthma but might have potential safety concerns.
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Affiliation(s)
- Bradley Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, California
| | - Ben Taylor
- Doctor Evidence, Santa Monica, California
| | - Valentina Bayer
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - Asif Shaikh
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - Giselle Mosnaim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois
| | - Jennifer Trevor
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Sheri Rogers
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | | | - Dara Paek
- Doctor Evidence, Santa Monica, California
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18
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Can C, Akkelle E, Gökmirza Özdemir P, Yazıcıoğlu M, Süt N. Assessment of regular drug use and inhaler technique skills in asthmatic children. Allergol Immunopathol (Madr) 2020; 48:124-129. [PMID: 31627970 DOI: 10.1016/j.aller.2019.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 06/22/2019] [Accepted: 06/27/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to assess the regular use of long-term asthma-control medication and to determine inhaler techniques in asthmatic children. METHODS The study was conducted on asthmatic children aged 6-18 years. Information on rescue and controller medications was given and the proper inhalation technique was demonstrated. One month later, patients and parents were asked to answer a questionnaire on drug use and to demonstrate their inhaler techniques. RESULTS One hundred children and/or their parents were interviewed for the study. All of the patients identified long-term asthma-control medications while quick-relief asthma medications were identified by 93% of the patients. Of the patients, 34% described the dose of their quick-relief medication correctly. All steps in the inhalation technique were correctly carried out by 60.6% of patients using a metered-dose inhaler (MDI), 80% of patients using a Turbuhaler, and 58% of patients using a capsule-based dry-powder inhaler (DPI). Of the participants, 73% reported regular use of long-term asthma-control medications. While the mean age of the patients regularly using long-term asthma medications was 9.05±2.5 years, that of patients not compliant with the regular treatment was 10.29±3.26 years (p=0.04). The most common reason for irregular drug use was forgetting to take the drug. CONCLUSION Adherence to long-term asthma-control medications tends to be better in younger patients. Since the most common cause of irregular drug use is forgetting to take the drug, repeated training is necessary to ensure asthma control and the successful treatment of asthmatic children.
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Affiliation(s)
- Ceren Can
- Department of Pediatric Allergy and Immunology, Trakya University Faculty of Medicine, Edirne, Turkey.
| | - Emre Akkelle
- Department of Pediatric Allergy and Immunology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Pınar Gökmirza Özdemir
- Department of Pediatric Allergy and Immunology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Mehtap Yazıcıoğlu
- Department of Pediatric Allergy and Immunology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Necdet Süt
- Department of Biostatistics, Trakya University Faculty of Medicine, Edirne, Turkey
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19
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Murphy KR, Hong JG, Wandalsen G, Larenas-Linnemann D, El Beleidy A, Zaytseva OV, Pedersen SE. Nebulized Inhaled Corticosteroids in Asthma Treatment in Children 5 Years or Younger: A Systematic Review and Global Expert Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1815-1827. [PMID: 32006721 DOI: 10.1016/j.jaip.2020.01.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 11/29/2019] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
Although nebulized corticosteroids (NebCSs) are a key treatment option for young children with asthma or viral-induced wheezing (VIW), there are no uniform recommendations on their best use. This systematic review aimed to clarify the role of NebCSs in children 5 years or younger for the management of acute asthma exacerbations, asthma maintenance therapy, and the treatment of VIW. Electronic databases were used to identify relevant English language articles with no date restrictions. Studies reporting efficacy data in children 5 years or younger, with a double-blind, placebo- or open-controlled, randomized design, and inclusion of 40 or more participants (no lower patient limit for VIW) were included. Ten articles on asthma exacerbation, 9 on asthma maintenance, and 7 on VIW were identified. Results showed NebCSs to be at least as efficacious as oral corticosteroids in the emergency room for the management of mild to moderate asthma exacerbations. In asthma maintenance, nebulized budesonide, the agent of focus in all trials analyzed, significantly reduced the risk of further asthma exacerbations compared with placebo, cromolyn sodium, and montelukast. Intermittent NebCS treatment of VIW was as effective as continuous daily treatment. In summary, NebCSs are effective and well tolerated in patients 5 years or younger for the management of acute and chronic asthma.
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Affiliation(s)
| | - Jian Guo Hong
- Department of Pediatrics, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Gustavo Wandalsen
- Division of Allergy and Clinical Immunology, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Olga V Zaytseva
- Department of Pediatrics, Moscow State University of Medicine and Dentistry named after A.I. Evdokimov Moscow, Russia
| | - Søren E Pedersen
- University of Southern Denmark, Odense, Denmark; Department of Pediatrics, Kolding Hospital, Kolding, Denmark
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20
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Stukus D. The missing link in pediatric asthma management. Ann Allergy Asthma Immunol 2020; 123:230-231. [PMID: 31477215 DOI: 10.1016/j.anai.2019.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022]
Affiliation(s)
- David Stukus
- Department of Pediatrics, Division of Allergy & Immunology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.
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21
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Kwong CG, Bacharier LB. Management of Asthma in the Preschool Child. Immunol Allergy Clin North Am 2019; 39:177-190. [PMID: 30954169 DOI: 10.1016/j.iac.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The management of asthma in the preschool population is challenging because disease phenotypes are heterogeneous and evolving. Available therapies aimed at preventing persistent symptoms and recurrent exacerbations include inhaled corticosteroids and leukotriene receptor antagonists; episodic use of inhaled corticosteroids and azithromycin may result in a decrease in exacerbations among children with intermittent disease. This article reviews an approach using patient characteristics for selecting initial treatment approaches based on disease phenotype, such as symptom patterns or evidence of atopic markers. Evidence for and against the use of oral corticosteroids during acute episodes and barriers to adherence and effective treatment are discussed.
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Affiliation(s)
- Christina G Kwong
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Campus Box 8116, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Campus Box 8116, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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22
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Murphy KR, Chipps BE. Tiotropium in children and adolescents with asthma. Ann Allergy Asthma Immunol 2019; 124:267-276.e3. [PMID: 31805357 DOI: 10.1016/j.anai.2019.11.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Asthma is a major cause of morbidity in children, despite the availability of various treatments. In adults, tiotropium-a long-acting muscarinic antagonist-as add-on therapy to an inhaled corticosteroid with or without a long-acting β2-agonist provides clinical benefit with a safety profile similar to placebo. OBJECTIVE To review published evidence on the efficacy and safety of tiotropium as add-on a long-acting muscarinic antagonist therapy in children and adolescents with asthma that is uncontrolled despite use of an inhaled corticosteroid with or without additional controller medication(s). METHODS We searched PubMed from inception until June 12, 2018, for randomized controlled trials of children and adolescents aged 1 to 17 years treated with tiotropium and reporting a primary outcome of any pulmonary function test and a secondary outcome of adverse events. RESULTS Overall, 7 randomized controlled trials of 1902 preschool children (aged 1-5 years; n = 102), school-age children (aged 6-11 years; n = 905), and adolescents (aged 12-17 years; n = 895) with moderate to severe asthma were included in the analysis. Once-daily tiotropium (5, 2.5, or 1.25 μg) improved lung function parameters, including peak and trough forced expiratory volume in 1 second, vs placebo. Commonly reported adverse events across treatment groups included asthma worsening or exacerbations, decreased peak expiratory flow rate, nasopharyngitis, viral respiratory tract infection, and respiratory tract infection. CONCLUSION Once-daily tiotropium as add-on therapy is efficacious and safe in adolescents and children with moderate to severe asthma. These results support the expanded indication by regulatory authorities for add-on tiotropium in patients 6 years or older.
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Affiliation(s)
- Kevin R Murphy
- Boys Town National Research Hospital, Boys Town, Nebraska
| | - Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
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23
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Marshall GD, Ellis A, Grayson M, Leung DYM, Lieberman J, Nowak-Wegrzyn A, Oppenheimer J. Best of 2019. Ann Allergy Asthma Immunol 2019; 124:111-115. [PMID: 31790813 DOI: 10.1016/j.anai.2019.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Gailen D Marshall
- Editor-in-Chief, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
| | - Anne Ellis
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada; Canada Allergy Research Unit, Kingston General Hospital, Kingston, Ontario, Canada; Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Mitchell Grayson
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Donald Y M Leung
- Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Jay Lieberman
- Pulmonary and Allergy Associates, Morristown, New Jersey
| | - Anna Nowak-Wegrzyn
- Elliott and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Department of Pediatrics, Kravis Children's Hospital, Icahn School of Medicine, New York, New York
| | - John Oppenheimer
- Pulmonary and Allergy Associates, Morristown, New Jersey; Department of Internal Medicine, New Jersey Medical School, Newark, New Jersey
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24
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Kalayci O, Abdelateef H, Pozo Beltrán CF, El-Sayed ZA, Gómez RM, Hossny E, Morais-Almeida M, Nieto A, Phipatanakul W, Pitrez P, Wong GW, Xepapadaki P, Papadopoulos NG. Challenges and choices in the pharmacological treatment of non-severe pediatric asthma: A commentary for the practicing physician. World Allergy Organ J 2019; 12:100054. [PMID: 31641403 PMCID: PMC6796770 DOI: 10.1016/j.waojou.2019.100054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/23/2019] [Accepted: 07/31/2019] [Indexed: 12/21/2022] Open
Abstract
In recent years, asthma research has focused intensely on the severe part of the disease spectrum, leading to new treatments, mostly therapeutic monoclonal antibodies. However, severe asthma accounts for not more than 2% of asthma in the pediatric population. Therefore, non-severe asthma remains a major health problem in children, not only for patients and parents but also for healthcare professionals such as general practitioners, pediatricians and allergists who take care of these patients. It is thus essential to identify and put in context novel concepts, applicable to the treatment of these patients. Recent evidence suggests benefits from using anti-inflammatory treatment even for the mildest cases, for whom until now only symptomatic bronchodilation was recommended. Likewise, “reliever” medication may be better combined with an inhaled corticosteroid (ICS). Among “new” treatments (for children), ICS formulation in ultrafine particles has showed promise and tiotropium is gaining access to the pediatric population. Maintenance and reliever therapy (MART) is an option for moderate disease. Most importantly, personalized response to medications appears to be considerable, therefore, it may need to be taken into account. Overall, these new options provide opportunities for multiple new management strategies. The deployment of such strategies in different populations remains to be evaluated.
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Affiliation(s)
- Omer Kalayci
- Pediatric Allergy and Asthma, Hacettepe University, School of Medicine, Ankara, Turkey
- Corresponding author.
| | - Hanan Abdelateef
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Zeinab A. El-Sayed
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Elham Hossny
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Antonio Nieto
- Pediatric Pulmonology & Allergy Unit Children's Hospital la Fe, 46026, Valencia, Spain
| | - Wanda Phipatanakul
- Pediatric Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Paulo Pitrez
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Gary Wk. Wong
- Department of Paediatrics, The Chinese University of Hong Kong, China
| | | | - Nikolaos G. Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
- Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK
- Corresponding author. Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK
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Szefler SJ, Vogelberg C, Bernstein JA, Goldstein S, Mansfield L, Zaremba-Pechmann L, Engel M, Hamelmann E. Tiotropium Is Efficacious in 6- to 17-Year-Olds with Asthma, Independent of T2 Phenotype. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2286-2295.e4. [PMID: 30922990 DOI: 10.1016/j.jaip.2019.03.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/07/2019] [Accepted: 03/12/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tiotropium add-on therapy has demonstrated efficacy and safety in 6- to 17-year-olds with symptomatic asthma despite treatment with inhaled corticosteroids (ICSs), with or without additional controllers. Pediatric patients often have a significant allergic component to their asthma. OBJECTIVE To explore whether responses to tiotropium add-on were influenced by patients' type 2 status, assessed by serum IgE levels and blood eosinophil counts. METHODS Data from 2 phase III trials in symptomatic moderate asthma (CanoTinA-asthma; RubaTinA-asthma) and 2 phase III trials in symptomatic severe asthma (VivaTinA-asthma; PensieTinA-asthma) were pooled by severity. Patients were treated with tiotropium 5 μg, tiotropium 2.5 μg, or placebo (2 puffs once daily via Respimat inhaler), as add-on to ICSs, with or without additional controllers. Modeling of efficacy outcomes was performed over the whole range of baseline IgE levels and blood eosinophil counts, and the treatment effect of the tiotropium doses was presented graphically. RESULTS Improvements with tiotropium in peak FEV1 within 3 hours postdose, trough FEV1, forced expiratory flow at 25% to 75% of the pulmonary volume, and FEV1/forced vital capacity responses were generally consistent across the range of baseline IgE levels and blood eosinophil counts. Risk of exacerbations and improvement in Asthma Control Questionnaire responder rates with tiotropium were also largely independent of IgE levels or eosinophil counts. CONCLUSIONS This exploratory analysis suggests that improvements with tiotropium as add-on to ICSs, with or without additional controllers, in 6- to 17-year-olds with symptomatic asthma do not vary according to systemic markers of T2 inflammation, namely, total IgE and blood eosinophil counts.
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Affiliation(s)
- Stanley J Szefler
- The Breathing Institute, Children's Hospital of Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
| | - Christian Vogelberg
- Department of Pediatric Pneumology and Allergology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Jonathan A Bernstein
- University of Cincinnati College of Medicine and Bernstein Clinical Research Center, Cincinnati, Ohio
| | | | | | - Liliana Zaremba-Pechmann
- Global Biometrics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Michael Engel
- TA Respiratory Diseases, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Eckard Hamelmann
- Children's Center Bethel, Evangelisches Klinikum Bethel, Bielefeld, Germany; Allergy Center of the Ruhr University, Bochum, Germany
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Lanz MJ, Gilbert I, Szefler SJ, Murphy KR. Can early intervention in pediatric asthma improve long-term outcomes? A question that needs an answer. Pediatr Pulmonol 2019; 54:348-357. [PMID: 30609252 PMCID: PMC6590791 DOI: 10.1002/ppul.24224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Although many children with asthma do not experience persistence into adulthood, recent studies have suggested that poorly controlled asthma in childhood may be associated with significant airflow obstruction in adulthood. However, data regarding disease progression are lacking, and clinicians are not yet able to predict the course of a child's asthma. The goal of this article was to assess the current understanding of childhood asthma treatment and progression and to highlight gaps in information that remain. DATA SOURCES Nonsystematic PubMed literature search and authors' expertise. STUDY SELECTION Articles were selected at the authors' discretion based on areas of interest in childhood asthma treatment and progression into adulthood. RESULTS Uncontrolled asthma in early childhood can potentially have lasting effects on lung development, but it is unclear whether traditional interventions in very young children preserve lung function. Although not all children respond to standard interventions, certain asthma phenotypes have been identified that can help to understand which children may respond to a particular treatment. CONCLUSION Clinicians should monitor children's asthma control and pulmonary function over time to assess the long-term impact of an intervention and to minimize the effect of uncontrolled asthma, especially exacerbations, on lung development. New biologic therapies have shown promise in treating adults with severe, uncontrolled asthma, and some of these therapies are approved in the United States for children as young as age 6. However, knowledge gaps regarding the efficacy and safety of these treatments in younger children hamper our understanding of their effect on long-term outcomes.
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Affiliation(s)
- Miguel J Lanz
- Allergy and Asthma, AAADRS Clinical Research Center, Coral Gables, Florida
| | | | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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Papadopoulos NG, Čustović A, Cabana MD, Dell SD, Deschildre A, Hedlin G, Hossny E, Le Souëf P, Matricardi PM, Nieto A, Phipatanakul W, Pitrez PM, Pohunek P, Gavornikova M, Jaumont X, Price DB. Pediatric asthma: An unmet need for more effective, focused treatments. Pediatr Allergy Immunol 2019; 30:7-16. [PMID: 30312503 PMCID: PMC7380053 DOI: 10.1111/pai.12990] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite remarkable advances in our understanding of asthma, there are still several unmet needs associated with the management of pediatric asthma. METHODS A two-day, face-to-face meeting was held in London, United Kingdom, on October 28 and 29, 2017, involving a group of international expert clinicians and scientists in asthma management to discuss the challenges and unmet needs that remain to be addressed in pediatric asthma. RESULTS These unmet needs include a lack of clinical efficacy and safety evidence, and limited availability of non-steroid-based alternative therapies in patients <6 years of age. An increased focus on children is needed in the context of clinical practice guidelines for asthma; current pediatric practice relies mostly on extrapolations from adult recommendations. Furthermore, no uniform definition of pediatric asthma exists, which hampers timely and robust diagnosis of the condition in affected patients. CONCLUSIONS There is a need for a uniform definition of pediatric asthma, clearly distinguishable from adult asthma. Furthermore, guidelines which provide specific treatment recommendations for the management of pediatric asthma are also needed. Clinical trials and real-world evidence studies assessing anti-immunoglobulin E (IgE) therapies and other monoclonal antibodies in children <6 years of age with asthma may provide further information regarding the most appropriate treatment options in these vulnerable patients. Early intervention with anti-IgE and non-steroid-based alternative therapies may delay disease progression, leading to improved clinical outcomes.
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Affiliation(s)
- Nikolaos G. Papadopoulos
- Division of Infection, Inflammation & Respiratory MedicineThe University of ManchesterManchesterUK
- The Allergy Department, 2nd Pediatric Clinic, National & KapodistrianUniversity of AthensAthensGreece
| | - Adnan Čustović
- Department of PaediatricsImperial College LondonLondonUK
| | - Michael D. Cabana
- Departments of Pediatrics and Epidemiology and Biostatistics, Philip R. Lee Institute for Health Policy StudiesUniversity of CaliforniaSan FranciscoCalifornia
| | - Sharon D. Dell
- Division of Respiratory Medicine, Department of Pediatrics, Child Health Evaluative Sciences, Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Antoine Deschildre
- CHU Lille, Pediatric Pulmonology and Allergy Unit, Hôpital Jeanne de FlandreCHRU de Lille and Université Nord de FranceLilleFrance
| | - Gunilla Hedlin
- Astrid Lindgren Children's Hospital, Lung and Allergy UnitKarolinska University HospitalStockholmSweden
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Elham Hossny
- Pediatric Allergy and Immunology UnitChildren's Hospital Ain Shams UniversityCairoEgypt
| | - Peter Le Souëf
- School of Paediatrics and Faculty of Child Health and Medical SciencesUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Paolo M. Matricardi
- Department of Pediatric Pneumology & ImmunologyCharité ‐ Universitätsmedizin BerlinBerlinGermany
| | - Antonio Nieto
- Pediatric Pulmonology & Allergy UnitChildren's Hospital La FeValenciaSpain
| | - Wanda Phipatanakul
- Pediatric Allergy and ImmunologyBoston Children’s HospitalBostonMassachusetts
| | - Paulo M. Pitrez
- School of MedicinePontifícia Universidade Católica do Rio Grande do Sul (PUCRS)Porto AlegreBrazil
| | - Petr Pohunek
- Pediatric Department, 2nd Faculty of MedicineCharles University Prague, and University Hospital MotolPragueCzech Republic
| | | | | | - David B. Price
- Observational and Pragmatic Research InstituteSingaporeSingapore
- University of AberdeenAberdeenUK
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Chipps BE, Bacharier LB, Murphy KR, Lang D, Farrar JR, Rank M, Oppenheimer J, Zeiger RS. The Asthma Controller Step-down Yardstick. Ann Allergy Asthma Immunol 2018; 122:241-262.e4. [PMID: 30550809 DOI: 10.1016/j.anai.2018.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/02/2018] [Accepted: 12/03/2018] [Indexed: 12/11/2022]
Abstract
Asthma guidelines recommend a control-based approach to disease management in which the assessment of impairment and risk is linked to step-based therapy. Using this model, controller treatment is adjusted-upward or downward-according to a patient's level of asthma control over time. Strategies for stepping up controller therapy are well described, and the adult and pediatric Asthma Yardsticks provide operational recommendations based on patient profiles. Strategies for stepping down controller treatment are less clear, although stepping down to the minimum effective therapy is important and should be considered when a patient's asthma has been well controlled for an adequate period as defined by risk and impairment. This Yardstick presents recommendations for when and how to step down asthma controller therapy according to guideline-defined control levels. The objective is to provide clinicians who treat patients with asthma with a practical and clinically relevant framework for implementing a step-down in controller therapy.
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Affiliation(s)
- Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
| | - Leonard B Bacharier
- Washington University School of Medicine and St. Louis Children's Hospital, Division of Allergy, Immunology and Pulmonary Medicine, Saint Louis, Missouri
| | - Kevin R Murphy
- Boys Town National Research Hospital, Boys Town, Nebraska
| | - David Lang
- Division of Allergy and Clinical Immunology, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Matthew Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona
| | | | - Robert S Zeiger
- Kaiser Permanente Southern California Region, Department of Allergy and Research and Evaluation, San Diego and Pasadena, California
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