Daily vs. intermittent inhaled corticosteroids for recurrent wheezing and mild persistent asthma: a systematic review with meta-analysis

Sex differences in excessive oral corticosteroid exposure in poor adherent adult asthmatics overusing short-acting β-2 agonists

BACKGROUND

We know that excessive short-acting β2-agonists (SABA) use in asthma may be associated to high exacerbation risks. We studied whether such excessive SABA consumption is connected with different higher oral corticosteroid (OC) prescriptions in the two sexes.

METHODS

In our prescribing database, we searched subjects aged 18-40 years that were prescribed at least one SABA package/year and/or at least two ICS or two ICS/LABA boxes/year to identify asthmatics. Their OC prescriptions/year were also examined. Subjects were divided into 4 groups according to SABA packages/year prescribed (0, 1-2,3-6 and ≥7), considering sexes separately.

RESULTS

Individuals recruited were 9,102. Subjects with at least one OC prescription were higher in each group and were females (P<0.001). The OC packages/year number was also more elevated in women especially those with >7 SABA prescriptions/year (0.96 in males vs. 2.64 in females, P<0.001). 94.7%/93.6% males/females, who never used SABA, took at least one ICS/LABA (mean 5.84/5.48 packages/year), while the subject percentage adhering to ICS/LABA dropped to 28-47% (mean 0.94-3.82 packages/year) in those who used SABA (P<0.001). Higher SABA prescriptions were associated with an increasing OC dispensation (β=0.057, P<0.0001). We observed also a greater risk of using >3 OC packages/year in subjects with 3-6 (OR: 2.98 [95% CI: 2.19-4.06], P<0.001) and ≥7 (OR: 3.49 [95% CI: 2.39-5.10], P<0.001) SABA prescriptions compared to those that never used SABA. Besides, we found that using ICS (OR:0.51 [95% CI: 0.35-0.75], P<0.001) or ICS/LABA (OR:0.07 [95% CI: 0.05-0.09], P<0.001) may significantly reduce SABA prescriptions.

CONCLUSIONS

Poor adherence to maintenance treatment appears to associated with excessive SABA prescriptions that may lead to a higher OC consumption particularly noticeable in women.

Use of inhaled corticosteroids on an intermittent or as-needed basis in pediatric asthma: a systematic review of the literature

OBJECTIVE

To summarize the principal findings of all available studies that have evaluated the use of inhaled corticosteroids (ICS) on an intermittent or as-needed basis as an add-on therapy to short-acting β2-agonists (SABAs) or fast-acting β2-agonists (FABAs) in pediatric asthmatic patients. Studies could either include or omit the use of ICS during stable periods of the disease.

DATA SOURCES

Electronic databases MEDLINE, EMBASE, CINAHL, SCOPUS, and the Cochrane Database of Systematic Reviews from inception to February 2021.

STUDY SELECTIONS

Relevant articles in the literature published by February 2021.

RESULTS

Of 294 references identified, 14 studies were included. The use of ICS on an intermittent or as-needed basis (as an add-on therapy to SABAs) has been shown to be more effective than treatment with SABA alone and to be similarly or less effective compared to regular daily ICS administration. Furthermore, strategies involving increasing the dose of ICS only when needed (as an add-on therapy to formoterol, a FABA) and keeping it low during stable stages of the disease (i.e. single maintenance and reliever therapy, SMART) have been shown to be similarly or more effective than comparators.

CONCLUSION

The use of ICS on an intermittent or as-needed basis as an add-on therapy to SABAs or FABAs, with or without ICS use during stable periods of the disease in pediatric asthmatic patients, encompasses several effective treatment strategies.

Management of Preschool Wheezing: Guideline from the Emilia-Romagna Asthma (ERA) Study Group

Preschool wheezing should be considered an umbrella term for distinctive diseases with different observable and measurable phenotypes. Despite many efforts, there is a large gap in knowledge regarding management of preschool wheezing. In order to fill this lack of knowledge, the aim of these guidelines was to define management of wheezing disorders in preschool children (aged up to 5 years). A multidisciplinary panel of experts of the Emilia-Romagna Region, Italy, addressed twelve different key questions regarding the management of preschool wheezing. Clinical questions have been formulated by the expert panel using the PICO format (Patients, Intervention, Comparison, Outcomes) and systematic reviews have been conducted on PubMed to answer these specific questions, with the aim of formulating recommendations. The GRADE approach has been used for each selected paper, to assess the quality of the evidence and the degree of recommendations. These guidelines represent, in our opinion, the most complete and up-to-date collection of recommendations on preschool wheezing to guide pediatricians in the management of their patients, standardizing approaches. Undoubtedly, more research is needed to find objective biomarkers and understand underlying mechanisms to assess phenotype and endotype and to personalize targeted treatment.

Inter-society consensus for the use of inhaled corticosteroids in infants, children and adolescents with airway diseases

Background

In 2019, a multidisciplinary panel of experts from eight Italian scientific paediatric societies developed a consensus document for the use of inhaled corticosteroids in the management and prevention of the most common paediatric airways disorders. The aim is to provide healthcare providers with a multidisciplinary document including indications useful in the clinical practice. The consensus document was intended to be addressed to paediatricians who work in the Paediatric Divisions, the Primary Care Services and the Emergency Departments, as well as to Residents or PhD students, paediatric nurses and specialists or consultants in paediatric pulmonology, allergy, infectious diseases, and ear, nose, and throat medicine.

Methods

Clinical questions identifying Population, Intervention(s), Comparison and Outcome(s) were addressed by methodologists and a general agreement on the topics and the strength of the recommendations (according to the GRADE system) was obtained following the Delphi method. The literature selection included secondary sources such as evidence-based guidelines and systematic reviews and was integrated with primary studies subsequently published.

Results

The expert panel provided a number of recommendations on the use of inhaled corticosteroids in preschool wheezing, bronchial asthma, allergic and non-allergic rhinitis, acute and chronic rhinosinusitis, adenoid hypertrophy, laryngitis and laryngospasm.

Conclusions

We provided a multidisciplinary update on the current recommendations for the management and prevention of the most common paediatric airways disorders requiring inhaled corticosteroids, in order to share useful indications, identify gaps in knowledge and drive future research.

[Effect of intermittent versus daily inhalation of budesonide on pulmonary function and fractional exhaled nitric oxide in children with mild persistent asthma]

OBJECTIVE

To study the effect of intermittent versus daily inhalation of budesonide on pulmonary function and fractional exhaled nitric oxide (FeNO) in children with mild persistent asthma.

METHODS

A total of 120 children, aged 6-14 years, with mild persistent asthma who attended the hospital from January 2016 to January 2018 were enrolled. The children were divided into an intermittent inhalation group with 60 children (inhalation of budesonide 200 μg/day for 6 weeks when symptoms of asthma appeared) and a daily inhalation group with 60 children (continuous inhalation of budesonide 200 μg/day) by stratified randomization. The children were followed up at months 3, 6, 9, and 12 of treatment. The two groups were compared in terms of baseline data, changes in FeNO and pulmonary function parameters, amount of glucocorticoid used, number of asthma attacks, and asthma control.

RESULTS

At the start of treatment, there were no significant differences in baseline data, FeNO, and pulmonary function between the two groups (P>0.05). Over the time of treatment, FeNO gradually decreased and pulmonary function parameters were gradually improved in both groups (P<0.001). Compared with the intermittent inhalation group, the daily inhalation group had a better effect in reducing FeNO and increasing the predicted percentage of forced expiratory volume in 1 second (FEV1%pred) (P<0.001). The inhalation method and treatment time had an interaction effect on FeNO and pulmonary function parameters (P<0.001). In the daily inhalation group, FeNO and lung function parameters were improved rapidly and stabilized after 3 months of treatment, while those in the intermittent inhalation group stabilized after 6 months. After 12 months of treatment, there were no significant differences in the increases in body height and body weight and the degree of disease control between the two groups (P>0.05). Compared with the daily inhalation group, the intermittent inhalation group had a significantly lower amount of budesonide inhaled (P<0.05) and a significantly higher number of asthma attacks (P<0.05).

CONCLUSIONS

Intermittent inhalation and daily inhalation of budesonide can achieve the same level of asthma control in children with mild persistent asthma and both have no influence on the increases in body height and body weight. Daily inhalation of budesonide can produce a better efficiency in reduing FeNO and increasing FEV1%pred. Although intermittent inhalation can reduce the amount of glucocorticoid used, it may lead to a higher risk of asthma attacks.

Preschool Wheezing: Trajectories and Long-Term Treatment

Wheezing is very common in infancy affecting one in three children during the first 3 years of life. Several wheeze phenotypes have been identified and most rely on temporal pattern of symptoms. Assessing the risk of asthma development is difficult. Factors predisposing to onset and persistence of wheezing such as breastfeeding, atopy, indoor allergen exposure, environmental tobacco smoke and viral infections are analyzed. Inhaled corticosteroids are recommended as first choice of controller treatment in all preschool children irrespective of phenotype, but they are particularly beneficial in terms of fewer exacerbations in atopic children. Other therapeutic options include the addition of montelukast or the intermittent use of inhaled corticosteroids. Overuse of inhaled steroids must be avoided. Therefore, adherence to treatment and correct administration of the medications need to be checked at every visit.

A review of the burden and management of mild asthma in adults - Implications for clinical practice

Mild asthma is present in 50-75% of patients with asthma and is defined by the Global Initiative for Asthma as asthma that can be well controlled with low-intensity treatments (Steps 1 and 2). Despite this definition, 'mild' asthma is often not well controlled in reality, and can have a significant impact on an individual's symptom burden and quality of life. We performed a PubMed literature search to investigate the burden of 'mild' asthma in the lives of patients, including future risk and asthma control, and the current management strategies. While clinical guidelines recommend long-term, daily, low-dose inhaled corticosteroids (ICS) for 'mild' asthma, published data suggest that ICS are often under-prescribed or used intermittently as symptoms arise. Furthermore, patients and physicians tend to overestimate disease control, impacting the accuracy of diagnosing 'mild asthma' and subsequent management. This disconnect may be amplified by miscommunication between patients and physicians, limited objective assessment of control, and differences in guidelines. As with moderate and severe asthma, current evidence supports early initiation of regular ICS in 'mild' asthma to address the underlying inflammation, achieve symptom control and reduce risk of exacerbations. Adherence to ICS treatment is key and can be improved by educating both patients and healthcare professionals. The results of this literature search challenge the term 'mild' asthma and suggest strategies to improve the proactive management of the disease to enable patients to live symptom-free.

Pivotal efficacy trials of inhaled corticosteroids in asthma

BACKGROUND

Inhaled corticosteroids (ICSs) are the mainstay of daily controller treatment for persistent and uncontrolled asthma. However, many clinicians are wary of ICSs because of safety concerns. Clinicians need to know the underlying efficacy data that support the use of ICSs to weigh efficacy against safety.

OBJECTIVE

To discuss efficacy data from pivotal trials to aid clinicians in their decisions to use ICSs.

METHODS

Key efficacy studies were selected to augment discussion.

RESULTS

Clinical studies have revealed that ICSs are effective in reducing the risk of exacerbations in both children and adults. ICSs also reduce the risk of hospitalization and asthma-related death, improve asthma symptoms, and improve quality of life. In addition, ICSs improve lung function and airway responsiveness and reduce airway inflammation and remodeling. In young children, ICSs improve daytime and nighttime symptoms, improve lung function, reduce the risk of exacerbations, and reduce the need for rescue medications. To date, evidence is conflicting about whether intermittent ICS treatment is as effective as daily ICS treatment. The possibility of lower efficacy of intermittent therapy needs to be weighed against a reduced risk of slowed growth in children.

CONCLUSION

ICSs effectively reduce the risk of exacerbations, hospitalizations, and asthma-related death and improve asthma symptoms, quality of life, lung function, and airway responsiveness. ICSs also reduce airway inflammation and remodeling. Intermittent therapy may not be as effective as daily therapy, and clinicians should weigh reduced efficacy against reduced risk of adverse effects, particularly slowed growth in children.

Eosinophilic esophagitis phenotypes: Ready for prime time?

Eosinophilic esophagitis (EoE) is one of the most common causes of reflux-like symptoms and feeding problems in children and food impaction and dysphagia in adults with a prevalence of 1:2500. Therapeutic options include diet, use of swallowed corticosteroids, or dilation. In the last several years, recent clinical and translational researches have identified some common and distinctive features, for example, the varying response to diet and medications. As EoE shares some characteristics with both asthma and inflammatory bowel disease, the advances in these fields suggest that various phenotypes may also exist in patients with EoE. Here, we provide a rationale for EoE phenotypes and provide some suggestions for potential phenotypes based on histology, molecular signature, response to therapy or dietary therapy.

Long-term treatment in pediatric asthma: an update on chemical pharmacotherapy

INTRODUCTION

Asthma is the most common chronic disease in childhood, affecting approximately 10% of all children, and is the leading cause of hospitalization in developed countries. In this paper we aimed to review the evidence on chemical pharmacotherapy for long-term treatment of pediatric asthma, according to the latest updates. Area covered: Long-term treatment, essential for controlling symptoms and reducing future risks including exacerbations and decline in lung function, includes control agents such as inhaled corticosteroids, long-acting beta2-adrenergic agonists, and leukotriene modifiers. More recent strategies based on the use of a biological drug such as omalizumab, which is a monoclonal antibody directed against immunoglobulin E (IgE), can be considered in selected patients with severe asthma. Expert opinion: In the near future, the challenge of childhood asthma treatment will be to improve the chemical drugs that already exist as well as to carefully characterize the several different asthma subtypes, with special regard to children with severe disease. A better definition of patient features, made possible by the current advanced knowledge of the pathobiology of severe asthma, can ultimately allow the identification of specific phenotypes and endotypes of severe asthma, aimed to personalize pharmacological treatment.

Treatment of asthma in young children: evidence-based recommendations

In the present review, we focus on evidence-based data for the use of inhaled corticosteroids (ICS), leukotriene receptor antagonist (LTRA), long-acting beta2-agonits (LABA) and oral corticosteroids (OCS), with a special emphasis on well-performed randomized clinical trials (RCTs) and meta-analyses of such trials for the chronic management of asthma/wheeze in infants and preschoolers. Results: Seven meta-analyses and 14 RCTs were reviewed. Daily ICS should be the preferred drug for infants/preschoolers with recurrent wheezing, especially in asthmatics. For those with moderate or severe episodes of EVW, the use of high intermittent ICS doses significantly reduce the use of OCS. There is no evidence of effect of intermittent ICS at low-moderate dose in preschoolers with mild EVW episodes. In preschoolers with asthma, there were no significant differences between daily vs. intermittent ICS in terms of asthma exacerbations with insufficient power to conclude to equivalence; however, for other asthma control outcomes, daily ICS works significantly better than intermittent ICS for older children. Daily ICS is superior to daily or intermittent LRTA for reducing symptoms, preventing exacerbations, and improving lung function. No RCTs testing combination therapy with ICS and LABA (or LTRA) were published in infant/preschoolers. Parent-initiation of OCS at the first sign of symptoms is not effective in children with recurrent wheezing episode. In terms of ICS safety, growth suppression is dose and molecule-dependent but it’s effect is not cumulative beyond the first year of therapy and may be associated with some catch-up growth while on or off therapy. Linear growth must be monitored as individual susceptibility to ICS drugs may vary considerably.

Pharmacotherapy of critical asthma syndrome: current and emerging therapies

The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.

Prevalence and Treatment of Children's Asthma in Rural Areas Compared with Urban Areas in Beijing

BACKGROUND

The prevalence of childhood asthma has been increasing in China. This study aimed to compare the prevalence, diagnosis, and treatment of asthmatic children from urban and rural areas in Beijing, China.

METHODS

Schools, communities, and kindergartens were randomly selected by cluster random sampling from urban and rural areas in Beijing. Parents were surveyed by the same screening questionnaires. On-the-spot inquiries, physical examinations, medical records, and previous test results were used to diagnose asthmatic children. Information on previous diagnoses, treatments, and control of symptoms was obtained.

RESULTS

From 7209 children in rural areas and 13,513 children in urban areas who completed screening questionnaires, 587 children were diagnosed as asthma. The prevalence of asthma in rural areas was lower than in urban areas (1.25% vs. 3.68%, χ2 = 100.80, P < 0.001). The diagnosis of asthma in rural areas was lower than in urban areas (48.9% vs. 73.9%, χ2 = 34.6, P < 0.001). Compared with urban asthmatic children (56.5%), only 35.6% of rural asthmatic children received inhaled corticosteroids (P < 0.05). The use of bronchodilators was also lower in rural areas than in urban areas (56.5% vs. 66.4%, χ2 = 14.2, P < 0.01).

CONCLUSION

The prevalence of asthma in children was lower in rural areas compared with children in the urban area of Beijing. A considerable number of children were not diagnosed and inadequately treated in rural areas.

Cost-utility analysis of daily versus intermittent inhaled corticosteroids in mild-persistent asthma

INTRODUCTION

Despite the many benefits that have been demonstrated by the continuous administration of inhaled corticosteroids (ICS) in persistent asthma, a new strategy for mild-asthma is emerging, consisting of using intermittent or as-needed ICS treatment in conjunction with short-acting beta2 agonists in response to symptoms. However, no previous studies have reported an economic evaluation comparing these two therapeutic strategies.

METHODS

A Markov-type model was developed in order to estimate costs and health outcomes of a simulated cohort of pediatric patients with persistent asthma treated over a 12-month period. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from official databases provided by the Colombian Ministry of Health. The main outcome was the variable "quality-adjusted life-years" (QALYs).

RESULTS

For the base-case analysis, the model showed that compared to intermittent ICS, daily therapy with ICS had lower costs (US$437.02 vs. 585.03 and US$704.62 vs. 749.81 average cost per patient over 12 months for school children and preschoolers, respectively), and the greatest gain in QALYs (0.9629 vs. 0.9392 QALYs and 0.9238 vs. 0.9130 QALYS for school children and preschoolers, respectively), resulting in daily therapy being considered dominant.

CONCLUSIONS

The present analysis shows that compared to intermittent therapy, daily therapy with ICS for treating pediatric patients with recurrent wheezing and mild persistent asthma is a dominant strategy (more cost effective), because it showed a greater gain in QALYs with lower total treatment costs.

Stepping down inhaled corticosteroids from scheduled to as needed in stable asthma: Systematic review and meta-analysis

BACKGROUND

Many patients with asthma are potentially overtreated, which results in unnecessary cost and unnecessary exposure to drugs that may result in adverse events. Step down helps reduce overtreatment, may mitigate these harms, and is advocated by major guidelines. Unfortunately, data that support step down are sparse.

OBJECTIVES

This systematic review aimed to examine the effect of stepping down from scheduled inhaled corticosteroids (ICS) to as-needed ICS in patients with stable asthma.

METHODS

Several electronic databases were systematically searched in April 2014. Articles were screened independently in duplicate. Studies were required to have at least a 12-week follow-up duration and to have compared stepping down from scheduled ICS to as-needed ICS and maintenance of scheduled ICS. Patients were required to have stable asthma as evidenced by at least 4 weeks without asthma exacerbation before intervention.

RESULTS

A total of 3025 abstracts were retrieved initially, 77 of which were retrieved for full-text screening. Of these, only two articles were found to be eligible for inclusion, both were randomized controlled trials. By using random effects meta-analysis, it was determined that, after a follow-up of 6-10 months, the relative risk of exacerbation of stepping down from scheduled to as-needed ICS was 1.32 (95% confidence interval [CI], 0.81-2.16; p = 0.27, I(2) = 0%). Those who did not step down had more symptom-free days (standard mean difference 0.26 [95% CI, 0.02-0.49; p = 0.03; I(2) = 22%]).

CONCLUSION

There is currently insufficient evidence to associate stepping down from scheduled to as-needed ICS with a change in exacerbations, although it may lead to fewer symptom-free days.

Special considerations--asthma in children

BACKGROUND

Asthma is among the most common chronic diseases of childhood. Management of pediatric asthma requires an understanding of the issues that uniquely effect children. This review provides the reader with the current state and future directions of pediatric asthma.

METHODS

Review of the pediatric asthma literature was undertaken with emphasis on randomized controlled trials and systematic reviews.

RESULTS

The prevalence of pediatric asthma remains elevated and is increasingly being appreciated in select global regions. Effective treatment in any setting begins with a focused medical history that queries key asthma features that inform both diagnostic and monitoring strategies. A thorough medical history may yield comorbid upper airway disorders and allergic triggers that could potentially exacerbate airway inflammation. Pre-bronchodilator and post-bronchodilator lung function testing is a preferable diagnostic strategy to quantitatively assess obstructive pulmonary disease among children capable of performing the testing maneuvers. Pediatric asthmatics who continue to have poor disease control require monitoring of medication adherence and drug delivery techniques, because both are often linked with disease outcomes. Therapeutic strategies in children are notably distinct from adults due to the possible effects of inhaled corticosteroids on reduced bone mineral density and growth. Adolescents may also require more time to address the psychosocial complexities that may complicate the required daily usage of asthma medicines.

CONCLUSION

Asthmatic children are distinct from their adult counterparts due to limitations inherent in the pediatric age group. A unified and evidence-based approach to pediatric asthma may improve clinical outcomes.

What lessons can be learned about asthma phenotypes in children from cohort studies?

'Phenotyping' asthma by multivariate analyses and more recently by unsupervised analysis has been performed in children cohorts. We describe the key findings that have emerged from these cohorts. It would appear that there are three wheeze phenotypes in children of preschool age: the mild episodic viral wheeze phenotype; the multitrigger atopic wheeze; and, less often encountered, the severe non-atopic wheeze. Early onset of allergy in asthma (more prevalent in boys) is associated with poor prognosis unlike the severe non-atopic wheeze phenotype which has a female predominance. The prognosis of the severe non-atopic wheeze depends on time of onset (early or late) of allergic expression. At school age, the risk of severe asthmatic exacerbations is associated with eosinophil predominant inflammation frequently related to allergic asthma, whereas neutrophil inflammation is associated with moderate-to-severe asthma with poorer lung function. Nevertheless, allergic asthma is also a heterogeneous disease with a severe allergic phenotype strongly associated with atopic dermatitis and very high eosinophil-driven inflammatory markers. Further studies are required to find non-invasive biological markers in very young children to better define wheezing phenotypes associated with an elevated risk of developing severe asthma with a view to personalizing treatment.

Daily versus intermittent inhaled corticosteroid treatment for mild persistent asthma

PURPOSE OF REVIEW

Guidelines recommend the use of daily inhaled corticosteroids as preferred treatment for preschoolers, children, adolescents, and adults with recurrent wheezing and mild persistent asthma. However, intermittent or as-needed inhaled corticosteroids treatment in response to symptoms is an emerging strategy. This review is focused on the analysis (clinical efficacy and safety) of this approach in comparison with the current daily-based therapy.

RECENT FINDINGS

Recently, some authors favored the use of inhaled corticosteroids based on symptoms. It has been suggested that a symptom-based approach could reduce the amount of drug used, minimize the risk of adverse events, and reduce healthcare costs. In contrast, physicians prescribing intermittent inhaled corticosteroids would give the wrong message to their patients about the chronicity of the disease. Currently, there is a significant body of high-quality clinical studies and systematic reviews that have addressed this important controversy, and whose analysis allows us to extract some important conclusions.

SUMMARY

Present evidence does not support a change in the direction of an intermittent or symptom-based use approach for recurrent wheezing and mild-to-moderate persistent asthma. At this point, there is no convincing basis to alter the current strategy to inhaled corticosteroids dosing, and more studies are needed comparing these two approaches.

Principal findings of systematic reviews for chronic treatment in childhood asthma

OBJECTIVE

To summarize the principal findings pertaining to most effective long-term pharmacologic treatment of childhood asthma.

METHODS

Systematic reviews of randomized clinical trials (SRCTs) on pharmacologic chronic treatment in children (1-18 years) with persistent asthma were retrieved through MEDLINE, EMBASE, CINAHL, SCOPUS, and CDSR (up to January2014).

RESULTS

One hundred eighty-three SRCTs were searched from databases. Among those, 39 SRCTs were included: two were related to step 1, 24 to step 2, nine to steps 3 and 4, and four to step 5 (according with NAEPP and GINA guidelines). The methodological quality of these SRCTs was determined by using the AMSTAR tool.

RESULTS

For step 1: addition of ipatropium bromide to short-acting beta2-agonists does not show any benefit. For step 2: in preschoolers, inhaled corticosteroids (ICSs) reduce severe exacerbations and improve other clinical and lung function parameters. In children, ICSs are superior to leukotriene receptor antagonist (LTRA), cromones, or xantines in reducing severe exacerbations, improving lung function and other clinical outcomes. Fluticasone propionate (FP) is better than beclomethasone dipropionate (BDP) or budesonide only for lung function; but similar to hydrofluoroalkane-BDP or to ciclosenide. Compared to low ICSs doses, moderate doses result in only better lung function, but this is not true for FP. For steps 3 and 4: adding LTRA to ICS confers a small benefit; adding LABA improves lung function but does not reduce exacerbations more than double or higher ICS doses. For step 5: adding omalizumab decreases exacerbations.

CONCLUSIONS

SRCTs are useful for guiding decisions in chronic childhood asthma treatment.

Childhood asthma: recent developments and update

PURPOSE OF REVIEW

The purpose of this review is to provide an update on childhood asthma specifically related to the underlying genetic background and pathophysiology of asthma and their interaction with environmental stimuli. We will also discuss emerging data in the field of disease phenotyping.

RECENT FINDINGS

The field of genetics is continuously evolving to expand our knowledge on the cause of disease. Childhood onset asthma has been related to atopy and exposure to early-life infections. More recently, phenotypes have been used to classify asthma as transient and persistent, but the association of each phenotype with the genetic origin of asthma is not clearly understood.

SUMMARY

This review covers the topics of genetics, epigenetics, pathophysiology, phenotypes and treatment as they relate to childhood asthma. Overall, it provides a basis for the future of asthma treatment through description of the current research.

Inhaled corticosteroids for asthma: on-demand or continuous use

Continuous inhaled corticosteroid treatment is highly effective in children and adults with mild persistent asthma, although some therapeutic benefits are not lost if treatment is delayed. Many patients do not adhere to continuous treatment with inhaled corticosteroids, but rather take them intermittently, usually at the time of increased symptoms. Based on these observations it has been proposed that for patients with mild persistent asthma inhaled corticosteroids should be used on-demand when symptoms are troublesome, rather than on a continuous basis. The article reviews the pharmacological properties of inhaled corticosteroids used in clinical trials of on-demand treatment, as well as the evidence for the efficacy and safety of on-demand compared with continuous inhaled corticosteroid treatment of mild persistent asthma in adults and children. The place of on-demand treatment with inhaled corticosteroids in the management of asthma is discussed, as well as future directions for different management strategies for this group.