What is the current recommended treatment for pediatric asthma?

From the Guidelines

The current recommended treatment for pediatric asthma is a stepwise approach based on symptom severity and control, with low-dose inhaled corticosteroids (ICS) such as fluticasone or budesonide as the preferred initial controller therapy for persistent asthma, as supported by the most recent and highest quality study 1.

Key Considerations

• For mild intermittent asthma, short-acting beta-agonists (SABAs) like albuterol are the primary rescue medication.
• For persistent asthma, low-dose ICS are the preferred initial controller therapy, with options including fluticasone (50-100 mcg twice daily) or budesonide (0.5-1 mg daily).
• As severity increases, treatment escalates to include combination therapy with ICS plus long-acting beta-agonists (LABAs) like fluticasone/salmeterol or budesonide/formoterol.
• For moderate to severe persistent asthma, higher-dose ICS, leukotriene modifiers (montelukast 4-5 mg daily for ages 6-14), or biologics like omalizumab may be added.

Important Evidence

• The PACT study 1 provides definitive evidence in support of guideline recommendations of low-dose ICS in treating children with mild-to-moderate persistent asthma with FEV1 ≥ 80% predicted.
• The Expert Panel Report 3 (EPR-3) 1 guidelines recommend inhaled corticosteroids as the preferred long-term control medication for initiating therapy in young children.

Treatment Goals

• Control inflammation and prevent bronchoconstriction.
• Use the lowest effective dose to maintain control while minimizing side effects.
• Regular reassessment of control and adjustment of therapy is essential.

Additional Recommendations

• All children should have a written asthma action plan detailing daily controller medications, rescue medications, and when to seek emergency care.
• Proper inhaler technique is crucial for effective medication delivery, often requiring spacer devices in younger children.

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 The patients had a mean baseline percent predicted FEV1 of 72% (approximate range, 45 to 90%) and a mean daily inhaled β-agonist requirement of 3. 4 puffs of albuterol. Approximately 36% of the patients were on inhaled corticosteroids. 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). The recommended dosage for asthma is XOLAIR 75 mg to 375 mg by subcutaneous injection every 2 or 4 weeks based on serum total IgE level (IU/mL) measured before the start of treatment and by body weight (kg) Pediatric patients 6 to <12 years of age: Initiate dosing according to Table 2.

The current recommended treatment for pediatric asthma includes:

• Montelukast (SINGULAIR): one 5-mg chewable tablet daily at bedtime for patients 6 to 14 years of age 2
• Omalizumab (XOLAIR): 75 mg to 375 mg by subcutaneous injection every 2 or 4 weeks based on serum total IgE level and body weight for patients 6 to <12 years of age 3 Key considerations:
• Treatment should be individualized based on the patient's disease severity and level of asthma control.
• The choice of treatment should be based on the patient's specific needs and medical history.

From the Research

Current Recommended Treatment for Pediatric Asthma

The current recommended treatment for pediatric asthma involves a stepwise approach, with the main goals of symptoms control and lung function preservation 4.

• First Line Therapy: Inhaled corticosteroids are the first line therapy for pediatric asthma, but may fail to reach control in more than one third of patients, especially adolescents 4.
• Alternative Therapies: For patients who do not respond to inhaled corticosteroids, alternative therapies such as omalizumab, a recombinant humanized monoclonal antibody, may be effective 4.
• Biologic Agents: Novel biologic drugs, including dupilumab, mepolizumab, reslizumab, and benralizumab, have shown promise in reducing annual exacerbation rates and steroid-use in glucocorticoid-dependent cases, but more research is needed to confirm their safety and efficacy in pediatric patients 4.
• Muscarinic Antagonists: The muscarinic antagonist tiotropium has been shown to be effective as a controller medication in pediatric settings, but more research is needed to confirm its safety and efficacy in children aged >6 years and in preschool children with persistent asthmatic symptoms 4.
• Inhaled Corticosteroids: New inhaled corticosteroids, such as ciclesonide and mometasone, have been shown to be effective as once-daily controller therapy, but long-term studies are needed to compare their effectiveness and safety to usual treatments 4.

Treatment Approaches for Severe Acute Asthma Exacerbations

For severe acute asthma exacerbations, a stepwise approach for escalating therapy is recommended, including the use of β-agonists, ipratropium, and steroids, as well as continuous β-agonists, intravenous magnesium, helium-oxygen mixtures, and non-invasive ventilation 5.

• Stepwise Approach: The stepwise approach involves continuous monitoring of the patient's cardiorespiratory status, serial clinical examinations, and objective scoring of asthma severity 5.
• Treatment Options: Treatment options for severe acute asthma exacerbations include β-agonists, ipratropium, steroids, continuous β-agonists, intravenous magnesium, helium-oxygen mixtures, and non-invasive ventilation 5.

Updates in Asthma Treatment

Recent updates in asthma treatment highlight the importance of a patient-specific approach, with a focus on guideline-based management and the use of corticosteroids, biologic agents, and other therapies 6.

• Guideline-Based Approaches: The National Asthma Education and Prevention Program and the Global Initiative for Asthma have developed guidelines for the management of asthma in children, with a focus on a stepwise approach to treatment 6.
• Emerging Treatments: Emerging treatments, including biologics, may be effective for patients who are difficult to treat, but more research is needed to confirm their safety and efficacy in pediatric patients 6.