Treatment of nocturnal asthma with nedocromil sodium

Managing Chronic Cough Due to Asthma and NAEB in Adults and Adolescents: CHEST Guideline and Expert Panel Report

BACKGROUND

Asthma and non-asthmatic eosinophilic bronchitis (NAEB) are among the commonest causes of chronic cough in adults. We sought to determine the role of non-invasive measurements of airway inflammation, including induced sputum and fractional exhaled nitric oxide, in the evaluation of cough associated with asthma, and what the best treatment is for cough due to asthma or NAEB.

METHODS

We undertook three systematic reviews of randomized controlled trials and observational trials of adults and adolescents > 12 years of age with a chronic cough due to asthma or NAEB. Eligible studies were identified in MEDLINE, CENTRAL, and SCOPUS and assessed for relevance and quality. Guidelines were developed and voted upon using CHEST guideline methodology.

RESULTS

Of the citations reviewed, 3/1,175, 53/656, and 6/134 were identified as being eligible for inclusion in the three systematic reviews, respectively. In contrast to established guidelines for asthma therapies in general and the inclusion in some guidelines for a role of biomarkers of airway inflammation to guide treatment in severe disease, the evidence of specific benefit related to the use of non-invasive biomarkers in patients with chronic cough due to asthma was weak. The best therapeutic option for cough in asthma or NAEB is inhaled corticosteroids followed by leukotriene receptor antagonism.

CONCLUSIONS

This guideline offers recommendations on the role of non-invasive measurements of airway inflammation and treatment for cough due to asthma or NAEB based on the available literature, and identifies gaps in knowledge and areas for future research.

Nedocromil sodium for chronic asthma in children

BACKGROUND

Currently inhaled corticosteroids are the main stay in the maintenance treatment of chronic asthma in children. Although inhaled corticosteroids play a crucial role in the management of childhood asthma, the long-term side effects of inhaled corticosteroids used in the management of chronic asthma in children are not clearly known.

OBJECTIVES

The objective of this review is to compare the safety and efficacy of inhaled nedocromil sodium with placebo in the treatment of chronic asthma in children.

SEARCH STRATEGY

We searched the Cochrane airway group trials register, Cochrane controlled trials register, Current contents, review articles, reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. We also searched abstracts of major respiratory society meetings. The last search was carried out in October 2004

SELECTION CRITERIA

Randomised placebo controlled trials comparing nedocromil sodium to placebo in the treatment of chronic asthma in children (0 to 18 years).

DATA COLLECTION AND ANALYSIS

Both authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Fifteen trials (twelve parallel group studies; three crossover trials recruiting 1422 children (837 males and 585 females)) were included. The studies were generally of good methodological quality. Two large long term studies used nedocromil for six months and four to six years and showed conflicting results in symptom free days. Short term studies (duration between 4 weeks to 12 weeks) showed that nedocromil sodium produced some improvement in a number of efficacy measures compared to placebo including FEV(1), FVC, FEV(1) % predicted, PC20 FEV(1), evening PEF and symptom scores. The parent's assessment of efficacy was in favour of nedocromil (odds ratio (OR) 0.5 (95% CI 0.3 to 0.8). Nedocromil sodium has a good safety profile. The only significant side effect observed was unpleasant taste. There was little evidence for a clinically dose response effect and only a few studies recruited participants with severe asthma.

AUTHORS' CONCLUSIONS

A limited number of small studies have shown that nedocromil is of benefit in improving lung function and some measures of symptoms, but the evidence with regard to the primary outcome of the review was conflicting. Two long-term trials did not show consistent effects on lung function outcomes, whereas several small short-term trials have shown benefit in these outcomes. Differing severities at baseline may explain this difference with milder participants experiencing less benefit, although the discrepancy between study findings may also reflect publication bias. Nedocromil sodium is associated with a very good safety profile with no significant short term or long- term adverse side effects. Although nedocromil may have advantages over inhaled corticosteroids in terms of side effects, there is a need for head to head trials of nedocromil and inhaled corticosteroids to establish whether asthma control is similar, especially in mild asthma. It is not yet clear where nedocromil should sit in relation to other therapies in the treatment of asthma in children.

Inhaled nedocromil sodium in symptomatic young children born prematurely

The efficacy of a non-steroidal anti-inflammatory agent (nedocromil sodium, NS) has been assessed in young children born prematurely who had recurrent respiratory symptoms at follow-up. In a randomized, double-blind cross-over trial, either two puffs of NS (2 mg puff-1) or placebo were administered three times a day via a spacer device and face mask. Fifteen children, median gestational age 27 weeks, birthweight 1100 g and postnatal age 12 months were studied. The symptom score was lower in the last 2 weeks of the active period (median score 26) compared to the run-in period (median score 55) and the last 2 weeks of the placebo period (median score 50), P < 0.01. The maximum possible symptom score for a 2-week period was 210. Compared to the run-in period, children required fewer days of bronchodilator therapy in the last 2 weeks of the active treatment (P < 0.01), but not in the placebo period. Although results of functional residual capacity (FRC) measurements were available on only 13 of the 15 children, these did demonstrate a significant change in FRC over the active, but not the placebo, period. These data suggest that NS is a useful prophylactic agent for children born prematurely and who are symptomatic at follow-up.