What is the best add-on therapy for child soccer players with partial relief from albuterol (bronchodilator) for asthma management?

From the Guidelines

For children with asthma who play soccer and have only partial relief from albuterol, the recommended add-on therapy is a low-dose inhaled corticosteroid (ICS) such as fluticasone (44-110 mcg twice daily), beclomethasone (80-160 mcg twice daily), or budesonide (180-360 mcg twice daily). This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of reducing airway inflammation in asthma management 1. The use of ICS as a daily controller medication, while maintaining albuterol as a rescue inhaler, is a well-established approach for managing persistent asthma.

Key Considerations

• Inhaled corticosteroids are the preferred long-term control medication for initiating therapy in children with asthma, as they have been shown to reduce impairment and risk of exacerbations 1.
• The benefits of ICSs outweigh any concerns about potential risks of a small, nonprogressive reduction in growth velocity or other possible adverse effects 1.
• For children whose asthma is not well controlled on low-dose ICS, adding a noncorticosteroid long-term control medication to medium-dose ICS may be considered before increasing the dose of ICS to high-dose 1.
• A leukotriene receptor antagonist like montelukast (5 mg daily for ages 6-14,4 mg daily for younger children) can be added or considered as an alternative to ICS for children 5-11 years old who remain symptomatic 1.

Important Reminders

• Parents should ensure proper inhaler technique, use a spacer device with metered-dose inhalers, and have the child rinse their mouth after ICS use to prevent oral thrush.
• A written asthma action plan should be shared with coaches, and the child should always have rescue medication available during soccer activities.
• Regular follow-up with a healthcare provider every 3-6 months is important to adjust therapy as needed based on symptom control and growth monitoring.

From the FDA Drug Label

The efficacy of SINGULAIR in pediatric patients 6 to 14 years of age was demonstrated in one 8-week, double-blind, placebo-controlled trial in 336 patients (201 treated with SINGULAIR and 135 treated with placebo) using an inhaled β-agonist on an “as-needed” basis Compared with placebo, treatment with one 5-mg SINGULAIR chewable tablet daily resulted in a significant improvement in mean morning FEV1 percent change from baseline (8.7% in the group treated with SINGULAIR vs 4.2% change from baseline in the placebo group, p<0. 001). There was a significant decrease in the mean percentage change in daily “as-needed” inhaled β-agonist use (11.7% decrease from baseline in the group treated with SINGULAIR vs 8.2% increase from baseline in the placebo group, p<0.05).

The best add-on therapy for child soccer players with partial relief from albuterol for asthma management is montelukast (SINGULAIR), as it has been shown to improve lung function and reduce the need for rescue medication in pediatric patients with asthma.

• Key benefits of montelukast include:
  • Improved lung function (FEV1)
  • Reduced need for rescue medication (albuterol)
  • Decreased asthma exacerbations 2

From the Research

Add-on Therapy for Child Soccer Players with Partial Relief from Albuterol

For child soccer players experiencing only partial relief from albuterol, a bronchodilator used for asthma management, the best add-on therapy can depend on several factors including the severity of asthma, the presence of allergic inflammation, and the patient's response to different medications.

• Inhaled Corticosteroids (ICS): Studies such as 3 and 4 suggest that ICS can be an effective add-on therapy for children with persistent asthma who have partial relief from albuterol. ICS are recommended as the first-line treatment for persistent asthma due to their anti-inflammatory properties.
• Leukotriene Receptor Antagonists (LTRAs): LTRAs, such as montelukast, are considered an alternative for children who cannot use ICS or have poor growth due to ICS use 3, 4. However, evidence from 4 indicates that ICS may be more effective than LTRAs in managing asthma symptoms in school-aged children.
• Considerations for Growth Suppression: It's crucial to consider the potential for growth suppression when using ICS in children. Research from 5 and 6 shows that regular use of ICS can lead to a small reduction in linear growth velocity, particularly in the first year of treatment. The effect may vary depending on the ICS molecule and dose.
• Dose-Response Effects: The study 6 found a small but statistically significant difference in growth velocity between low and low to medium doses of ICS, favoring the use of the lowest effective dose to minimize growth suppression.

Key Points for Decision Making

• The choice of add-on therapy should be individualized based on the child's specific needs and response to treatment.
• ICS are generally preferred for their efficacy in controlling asthma symptoms, but their potential impact on growth should be monitored.
• LTRAs can be a viable alternative for certain patients, especially when ICS are not suitable.
• The minimal effective dose of ICS should be used to balance efficacy with the risk of growth suppression.