Treatment of childhood asthma with sodium cromoglycate and beclomethasone dipropionate aerosol singly and in combination

Corticosteroid-sparing effect of chromoglycate sodium and nedocromil

The most appropiate management for bronchial asthma is the control of airway inflammation. Corticosteroids are the most effective anti-inflammatory drugs available, but they have a number of side effects; most of these are dose-dependent. In children, asthma control should be accomplished with low steroid doses possibly given by inhalation. In a double-bind placebo-controlled crossover study a group of children with mild to moderate asthma received NED 16 mg/day or BDP 400 μg/day. Values for FEV₁, PEF, symptoms use ofbronchodilators overlapped, whereas bronchial hyper-responsiveness assessed by histamine bronchoprovocation challenge was better with BDP than NED. In another case, one boy with high bronchial hyper-reactivity assessed by provocation test with hypertonic solution, experienced a significant improvement only after 2 weeks of therapy with Deflazacort (2 mg/Kg/day) followed by 4 months on combined treatment with NED (16 mg/day) and BDP (300 μ/day). Authors conclude that NED could have a steroidsparing effect over long-term use.

The actual role of sodium cromoglycate in the treatment of asthma--a critical review

INTRODUCTION

Despite international consensus and clearly written guidelines urging wider use of corticosteroids or combinations of inhaled short- and long-acting β-agonists (SABA and LABA) and corticosteroids in persistent asthma, prescribing patterns and compliance rates fall far short of recommendations.

OBJECTIVES

The failure to use steroids more aggressively is due, in part, to their side effects, even with inhaled forms of the drug. There is a role for expanded use of sodium cromolyn in asthma. Its potent anti-inflammatory effects, lack of side effects, and acceptable dosing and method of delivery, as well as its special role in exercise-induced asthma, make it a very suitable choice in the initial therapy for control of asthma.

CONCLUSION

Compared to SABA and LABA, cromoglycates alone are unsuspicious of being used to enhance physical performance.

Inhaled sodium cromoglycate for asthma in children

BACKGROUND

Sodium cromoglycate has been recommended as maintenance treatment for childhood asthma for many years. Its use has decreased since 1990, when inhaled corticosteroids became popular, but it is still used in many countries.

OBJECTIVES

To determine the efficacy of sodium cromoglycate compared to placebo in the prophylactic treatment of children with asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trials Register (October 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2007), MEDLINE (January 1966 to November 2007), EMBASE (January 1985 to November 2007) and reference lists of articles. We also contacted the pharmaceutical company manufacturing sodium cromoglycate. In 2007 we updated the review.

SELECTION CRITERIA

All double-blind, placebo-controlled randomised trials, which addressed the effectiveness of inhaled sodium cromoglycate as maintenance therapy, studying children aged 0 up to 18 years with asthma.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We pooled study results.

MAIN RESULTS

Of 3500 titles retrieved from the literature, 24 papers reporting on 23 studies could be included in the review. The studies were published between 1970 and 1997 and together included 1026 participants. Most were cross-over studies. Few studies provided sufficient information to judge the concealment of allocation. Four studies provided results for the percentage of symptom-free days. Pooling the results did not reveal a statistically significant difference between sodium cromoglycate and placebo. For the other pooled outcomes, most of the symptom-related outcomes and bronchodilator use showed statistically significant results, but treatment effects were small. Considering the confidence intervals of the outcome measures, a clinically relevant effect of sodium cromoglycate cannot be excluded. The funnel plot showed an under-representation of small studies with negative results, suggesting publication bias.

AUTHORS' CONCLUSIONS

There is insufficient evidence to be sure about the efficacy of sodium cromoglycate over placebo. Publication bias is likely to have overestimated the beneficial effects of sodium cromoglycate as maintenance therapy in childhood asthma.

Inhaled corticosteroids versus sodium cromoglycate in children and adults with asthma

BACKGROUND

Inhaled corticosteroids (ICS) and sodium cromoglycate (SCG) have become established as effective controller medications for children and adults with asthma, but their relative efficacy is not clear.

OBJECTIVES

To compare the relative effectiveness and adverse effects of ICS and SCG among children and adults with chronic asthma.

SEARCH STRATEGY

Systematic search of the Cochrane Airways Group's special register of controlled trials (to Feb. 2004), hand searches of the reference lists of included trials and relevant review papers, and written requests for identification of additional trials from pharmaceutical manufacturers.

SELECTION CRITERIA

Randomized controlled trials comparing the effect of ICS with SCG in children and adults with chronic asthma.

DATA COLLECTION AND ANALYSIS

All studies were assessed independently for eligibility by three review authors. Disagreements were settled by consensus. Trial authors were contacted to supply missing data or to verify methods. Eligible studies were abstracted and fixed- and random-effects models were implemented to pool studies. Separate analyses were conducted for paediatric and adult studies. Subgroup analyses and meta-regression models were fit to explore heterogeneity of lung function outcomes by type of RCT, category of ICS or SCG dosage, asthma severity of participants, and study quality on outcomes.

MAIN RESULTS

Of 67 identified studies, 17 trials involving 1279 children and eight trials involving 321 adults with asthma were eligible. Thirteen (76%) of the paediatric studies and six (75%) of the adult studies were judged to be high quality. Among children, ICS were associated with a higher final mean forced expiratory volume in 1 second [FEV1] (weighted mean difference [WMD] 0.07 litres, 95% confidence interval [CI] 0.02 to 0.11) and higher mean final peak expiratory flow rate [PEF] (WMD 17.3 litres/minute, 95% CI 11.3 to 23.3) than SCG. In addition, ICS were associated with fewer exacerbations (WMD -1.18 exacerbations per year, 95% CI -2.15 to - 0.21), lower asthma symptom scores, and less rescue bronchodilator use than SCG. There were no group differences in the proportion of children with adverse effects. Among adults, ICS were similarly associated with a higher mean final FEV1 (WMD 0.21 litres, 95% CI 0.13 to 0.28) and a higher final endpoint PEF (WMD 28.2 litres/minute, 95% CI 18.7 to 37.6) than SCG. ICS were also associated with fewer exacerbations (WMD -3.30 exacerbations per year, 95% CI -5.62 to -0.98), lower asthma symptom scores among cross-over trials but not parallel trials, and less rescue bronchodilator use than SCG. There were no differences in the proportion of adults with adverse effects. In subgroup analyses involving lung function measures, paediatric and adult studies judged to be of high quality had results consistent with the overall results. Lung function measures in children were higher in studies with medium BDP-equivalent steroid dosages than low BDP-equivalent dosages, while adult studies could not be compared by steroid dosage since they all incorporated similar dosages. There were no significant differences in lung function by the asthma severity of participants for adult or child studies.

AUTHORS' CONCLUSIONS

ICS were superior to SCG on measures of lung function and asthma control for both adults and children with chronic asthma. There were few studies reporting on quality of life and health care utilization, which limited our ability to adequately evaluate the relative effects of these medications on a broader range of outcomes. Although there were no differences in adverse effects between ICS and SCG, most trials were short and may not have been of sufficient duration to identify long-term effects. Our results support recent consensus statements in the U.S. and elsewhere that favour the use of ICS over SCG for control of persistent asthma.

Inhaled sodium cromoglycate for asthma in children

BACKGROUND

Sodium cromoglycate has been recommended as maintenance treatment for childhood asthma for many years. Its use has decreased since 1990, when inhaled corticosteroids became popular, but it is still used in many countries.

OBJECTIVES

To determine the efficacy of sodium cromoglycate compared to placebo in the prophylactic treatment of children with asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Asthma trials register (November 2002), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2002), MEDLINE (January 1966 to November 2002), EMBASE (January 1985 to November 2002) and reference lists of articles. We also contacted the pharmaceutical company manufacturing sodium cromoglycate

SELECTION CRITERIA

All double-blind placebo-controlled randomised trials, which addressed the effectiveness of inhaled sodium cromoglycate as maintenance therapy, studying children aged 0 up to 18 years with asthma.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study results were pooled.

MAIN RESULTS

Of 3500 titles retrieved from the literature, 25 papers reporting on 24 studies could be included in the review. The studies were published between 1970 and 1997 and together included 1074 participants. Most were cross-over studies. Few studies provided sufficient information to judge the concealment of allocation. Four studies provided results for the proportion of symptom-free days. Pooling the results did not reveal a statistically significant difference between sodium cromoglycate and placebo. For most of the other outcomes, the results were similar: small effect size and a confidence interval including the point of no difference. The funnel plot showed an under representation of small studies with negative results, suggesting publication bias.

REVIEWER'S CONCLUSIONS

The evidence of the efficacy of sodium cromoglycate over placebo is not proven. Publication bias is likely to have overestimated the beneficial effects of sodium cromoglycate as maintenance therapy in childhood asthma.

The effects of cromolyn sodium and nedocromil sodium in early asthma prevention

The possibility of irreversible obstruction and therefore the need for early intervention is being much debated. Some investigators suggested that delay in starting inhaled corticosteroids will result in irreversible obstruction. Our own long-term study, specifically designed to detect irreversible obstruction showed that a step-wise approach (starting with cromolyn sodium and switching to inhaled corticosteroids if clinical control and pulmonary function tests are not satisfactorily controlled) resulted in an increase in pulmonary function and not a deterioration. There was no evidence that a delay in starting inhaled corticosteroids will result in irreversible obstruction or clinical worsening. However, delay in starting cromolyn sodium in patients treated with bronchodilators alone did result in worsening pulmonary function tests and worse clinical outcomes. One study from Finland and another study from Australia came to the same conclusion. Even though some studies with cromolyn sodium did not show benefit in the first year of life, other studies did show a good response. The choice between nonsteroidal drugs, such as cromolyn sodium and inhaled corticosteroids as first-line drugs, has to be made on the risk/benefit ratio of these drugs. Although in severe asthma inhaled corticosteroids have greater efficacy, in mild-to-moderate asthma there is comparable efficacy, and the nonsteroidal drugs have better safety. A step-wise approach is still a logical approach

Canadian Asthma Consensus Report, 1999. Canadian Asthma Consensus Group

OBJECTIVES

To provide physicians with current guidelines for the diagnosis and optimal management of asthma in children and adults, including pregnant women and the elderly, in office, emergency department, hospital and clinic settings.

OPTIONS

The consensus group considered the roles of education, avoidance of provocative environmental and other factors, diverse pharmacotherapies, delivery devices and emergency and in-hospital management of asthma.

OUTCOMES

Provision of the best control of asthma by confirmation of the diagnosis using objective measures, rapid achievement and maintenance of control and regular follow-up.

EVIDENCE

The key diagnostic and therapeutic recommendations are based on the 1995 Canadian guidelines and a critical review of the literature by small groups before a full meeting of the consensus group. Recommendations are graded according to 5 levels of evidence. Differences of opinion were resolved by consensus following discussion.

VALUES

Respirologists, immunoallergists, pediatricians and emergency and family physicians gave prime consideration to the achievement and maintenance of optimal control of asthma through avoidance of environmental inciters, education of patients and the lowest effective regime of pharmacotherapy to reduce morbidity and mortality.

BENEFITS, HARMS AND COSTS

Adherence to the guidelines should be accompanied by significant reduction in patients' symptoms, reduced morbidity and mortality, fewer emergency and hospital admissions, fewer adverse side-effects from medications, better quality of life for patients and reduced costs.

RECOMMENDATIONS

Recommendations are included in each section of the report. In summary, after a diagnosis of asthma is made based on clinical evaluation, including demonstration of variable airflow obstruction, and contributing factors are identified, a treatment plan is established to obtain and maintain optimal asthma control. The main components of treatment are patient education, environmental control, pharmacotherapy tailored to the individual and regular follow-up.

VALIDATION

The recommendations were distributed to the members of the Canadian Thoracic Society Asthma and Standards Committees, as well as members of the board of the Canadian Thoracic Society. In addition, collaborating groups representing the Canadian Association of Emergency Physicians, the Canadian College of Family Physicians, the Canadian Paediatric Society and the Canadian Society of Allergy and Immunology were asked to validate the recommendations. The recommendations were discussed at regional meetings throughout Canada. They were also compared with the recommendations of other similar groups in other countries. DISSEMINATION AND IMPLEMENTATION: An implementation committee has established a strategy for disseminating these guidelines to physicians, other health professionals and patients and for developing tools and means that will help integrate the recommendations into current asthma care. The plan is outlined in this report.

Alternative agents for anti-inflammatory treatment of asthma

Recent guidelines for the management of asthma have emphasized the role of inflammation in persistent asthma. Medications with anti-inflammatory properties are recommended as the primary long-term-control medications. Of the available choices of long-term-control medications, inhaled corticosteroids are the preferred medication. A literature review of the available studies supports this recommendation of inhaled corticosteroids as the preferred agents for long-term control. Other long-term-control medications--specifically nedocromil, theophylline, and leukotriene modifiers, but not cromolyn--can supplement the beneficial effect of inhaled corticosteroids on pulmonary function and symptom control. Long-acting beta2-adrenergic agonists can also provide an additive clinical benefit to inhaled corticosteroids on symptom control and pulmonary function, but they do not provide additional anti-inflammatory effect. Extended long-term studies of each of the long-term-control medications with anti-inflammatory actions are needed to assess their specific effect on airway remodeling and on the natural history of asthma.

Comparison of fluticasone propionate and sodium cromoglycate for the treatment of childhood asthma (an open parallel group study)

Inhaled corticosteroids are highly effective in the treatment of asthma at all ages and their use in younger children is increasing. As concerns exist about the long-term systemic side-effects of high dose inhaled corticosteroids, current guidelines continue to recommend sodium cromoglycate (SCG) as first line regular medication for children with frequent symptoms. Few published studies have compared the safety and efficacy of inhaled corticosteroids with SCG in children. This study compares SCG with the new inhaled corticosteroid, fluticasone propionate (FP), which has theoretical advantages over other currently available corticosteroids due to its negligible oral bioavailability. This was a randomized, open, multi-centre, parallel group comparison of 50 micrograms FP twice daily and 20 mg SCG four times daily over 8 weeks, preceded by a 2-week baseline period. Sixty-two general practices and two hospital centres enrolled 225 asthmatic children aged 4-12 years (110 received FP; 115 received SCG). Outcome measures improved in both groups, with a significant difference in favour of FP for the key variables of mean morning and evening % predicted PEFR and % of symptom-free days and nights. No significant difference was observed for FEV1, or relief medication use. Two children taking FP and 10 children taking SCG withdrew because of adverse events. This study showed that low dose FP was effective and superior to SCG in young children with mild-moderate asthma. Safety studies of longer duration are needed before changing the current recommendations for inhaled corticosteroid therapy.

Comparison between sodium cromoglycate (MDI: metered-dose inhaler) and beclomethasone dipropionate (MDI) in treatment of adult patients with mild to moderate bronchial asthma. A double-blind, double-dummy randomized, parallel-group study

This study compared the efficacy and tolerability of sodium cromoglycate (SC) and beclomethasone dipropionate (BDP) in adult patients with bronchial asthma inadequately treated with bronchodilators alone. The study was a double-blind, randomized, double-dummy, parallel-group study. Patients with mild to moderate symptomatic asthma, inadequately treated with bronchodilators only, were, after a 2-week run-in (base-line) period, randomized to 8 weeks of treatment with either SC 10 mg four times daily or BDP 100 micrograms four times daily. Salbutamol metered-dose inhaler was given as relief medication. A total of 37 patients were randomized for treatment, 19 patients in the SC group and 18 patients in the BD group. Efficacy and safety were determined by daily record card data: morning and evening peak-expiratory-flow rates (PEFR), daytime and nighttime asthma symptom scores, and rescue salbutamol use. At clinic visits, FEV1 and FVC were measured, as were the physician's and the patient's assessment of the medication at the end of the study. The safety and tolerability of the trial medication were assessed by monitoring adverse events throughout the study. A clinically and statistically significant improvement of the asthma in FEV1, symptom scores, rescue medication, and global opinion of efficacy was observed, and both groups provided equivalent efficacy. The morning PEFR as well as the evening PEFR for both groups improved, but was statistically significant only for the BDP group (M-PEFR). Both drugs were well tolerated with only a few minor adverse events. This trial shows that SC and BDP are equally effective anti-inflammatory treatments for mild to moderate bronchial asthma in adults.

Nedocromil sodium is more effective than cromolyn sodium for the treatment of chronic reversible obstructive airway disease

In a multicenter, double-blind, group comparative trial, the efficacy of nedocromil sodium (nedocromil, 4 mg, four times daily [qid]), cromolyn sodium (2 mg, qid), and placebo was compared in patients receiving inhaled beta 2-agonists and inhaled corticosteroids for the treatment of chronic reversible obstructive airway disease. After a 2-week baseline period, 132 patients (8 centers) between the ages of 20 and 75 years entered a 4-week run-in period in which the dose of inhaled corticosteroid was reduced by 50 percent. During the run-in phase, deterioration of symptoms (total symptom score) by ten points qualified patients to enter the 6-week drug trial period. Patients in the nedocromil treatment group showed the most robust and consistent improvements over placebo and cromolyn sodium for all daily dairy variables. Statistically significant improvements over placebo were noted for both active treatment groups for daytime, nighttime, and total symptom score. Symptom scores for nedocromil were statistically significantly improved over both cromolyn sodium and placebo for both daytime and nighttime asthma. Patients treated with nedocromil also demonstrated a significant reduction in the use of nighttime as needed (prn) beta 2-agonists as compared with either the placebo- or cromolyn sodium-treated groups. Only nedocromil-treated patients demonstrated a statistically significant improvement in morning peak expiratory flow rate (PEFR) as compared with placebo. Both nedocromil and cromolyn sodium groups demonstrated statistically significant improvements in afternoon and evening PEFRs. Collectively, the improvements in nighttime symptoms, decreased bronchodilator use, and improved morning PEFR show that patients treated with nedocromil had improved nocturnal symptoms. Pulmonary function tests (FEV1, FVC, PEFR) demonstrated no statistically significant differences between the two active treatments, although trends favored nedocromil for both FEV1 and PEFR. Although symptoms improved in patients treated with cromolyn sodium, the level of symptom control was less than that achieved by nedocromil. As compared with baseline control (regular dose of inhaled steroids), patients treated with nedocromil plus the 50 percent reduced dosage of inhaled corticosteroid consistently demonstrated comparable or better symptom control. Although both active drugs reduced symptoms, nedocromil proved to be more effective than cromolyn sodium for treatment of reversible obstructive airway disease in patients normally well maintained on regimens of low to moderate doses of inhaled corticosteroids.

The use of inhaled steroids in young children

There are apparently irreversible inflammatory changes in the airways of young adults with chronic asthma so a strong case can be made for starting anti-inflammatory treatment early. Corticosteroids have potent and diverse anti-inflammatory activity. High efficacy is established in school age children. Trials in pre-school children and infants have given more mixed results perhaps because of problems with administration. No clinically important systemic effects have been observed in children taking conventional doses of inhaled steroids.

Cromolyn versus triamcinolone acetonide for youngsters with moderate asthma

Although both cromolyn (C) and inhaled corticosteroids are anti-inflammatory therapies for childhood asthma, there are few controlled comparisons of these medications for asthma therapy in children. None were conducted in the United States, and none specifically study triamcinolone acetonide (T) versus C. This 12-week evaluation followed 31 youths, aged 8 to 18 years, with moderate asthma who were assigned to receive C or T according to a prerandomized and blinded code. Patients were instructed to take two inhalations from the study metered-dose inhaler (active T or placebo) and to inhale the contents of one study-provided ampule (C, 20 mg, or placebo) from a compressor-driven home nebulizer three times per day. Patients also used albuterol, two inhalations from a metered-dose inhaler, three times a day (before study medication) and, additionally, if needed. Patients maintained a daily diary, recording extra medication use, adverse experiences, peak flow rates morning and night, and asthma symptom scores. Laboratory assessment of pulmonary function was done at 1, 4, 8, and 12 weeks. Cosyntropin challenge and methacholine bronchoprovocation challenge were performed at the beginning and end of the study. C and T provided similar, adequate asthma control. Symptoms of wheezing, cough, and chest tightness decreased, and daily peak expiratory flow rate increased with both regimens compared to during a 2-week baseline when patients received medication only as needed. There was no significant change in methacholine sensitivity and no change in endocrine function, as measured with fasting plasma control before and after administration of cosyntropin.(ABSTRACT TRUNCATED AT 250 WORDS)

Disodium cromoglycate compared with beclomethasone dipropionate in juvenile asthma

In a double-blind controlled crossover trial of inhaled disodium cromoglycate and beclomethasone dipropionate in juvenile asthma, beclomethasone produced higher therapeutic scores but significantly so in only two indices--wheeze-free days and morning peak flow rates. Combined treatment offered no advantage over beclomethasone alone. No side-effects were noted. The findings confirm other studies of cromoglycate and a steroid aerosol (betamethasone 17-valerate) but disagree with the only other comparative trial of cromoglycate and beclomethasone, in which both were found equally effective.

Beclomethasone dipropionate. A reappraisal of its pharmacodynamic properties and therapeutic efficacy after a decade of use in asthma and rhinitis

Inhaled beclomethasone dipropionate is now well established in the management of asthma. Studies conducted over the last decade, and since the drug was previously reviewed in the Journal, have confirmed that inhaled beclomethasone dipropionate 400 to 800 micrograms daily can reduce the need for oral maintenance corticosteroids in the majority of asthmatic patients requiring such therapy, and that increasing the dosage to 2000 micrograms daily may provide additional clinical benefit in some patients unresponsive to usual therapeutic dosages. Follow-up over a period of several years has confirmed that the initial response to inhaled beclomethasone can be maintained in most patients. Recent studies indicate that beclomethasone dipropionate 400 micrograms daily is equally effective when administered in 2 or 4 divided doses in patients with stable asthma, but it is likely that the lower frequency of administration will be less effective when the asthma is unstable. Recent studies have established the usefulness and good tolerability of intranasal beclomethasone dipropionate in the treatment of perennial and seasonal rhinitis, where the drug has been shown to be more effective than intranasal sodium cromoglycate and similar in efficacy to flunisolide. Nasal polyps decrease in size during continuous treatment with intranasal beclomethasone dipropionate, but enlarge again during periods of respiratory infection. After a decade of treatment with inhaled and intranasal beclomethasone dipropionate, there is no evidence that the drug damages the tracheobronchial lining or the nasal mucosa. Thus, the initial promise of beclomethasone dipropionate has been fulfilled. It has had an important role in asthma therapy over the past decade, which will continue into the future.

The combined use of betamethasone valerate and sodium cromoglycate in the treatment of asthma

A double-blind comparison of betamethasone valerate, sodium cromoglycate and the combination of these two treatments was carried out in twenty-two adult patients with asthma. Regular fortnightly assessments were made in the clinic throughout the study and adrenal function was monitored and found to be normal. All patients measured their peak expiratory flow rates in the morning and evening and monitored their symptoms daily on a record card as well as recording bronchodilator usage. Assessment using these parameters indicated that treatment with betamethasone valerate compared with sodium cromoglycate resulted in an improvement in the patients' asthma which was stitistically significant (P less than 0-001). Overall the combined treatment produced a better response than sodium cromoglycate (P less than 0-02) but a poorer response compared with the steroid aerosol given alone (P greater than 0-05). In only two patients was the response to the combined therapy significantly greater than to either drug given alone.