What are the recommendations about Maintenance and Reliever Therapy (MART) for asthma in pediatrics?

From the Guidelines

Maintenance and Reliever Therapy (MART) is not recommended for children under 12 years with asthma, and instead, inhaled corticosteroids (ICS) are the preferred long-term control medication for initiating therapy in this age group. The decision to start long-term daily therapy in pediatric patients with asthma should be based on consideration of issues regarding diagnosis and prognosis, including the presence of a positive asthma predictive index, frequency of wheezing episodes, and response to symptomatic treatment 1. For young children, the preferred treatment options are based on individual drug efficacy studies, and the doses received may vary considerably among devices and age groups 1.

Key Considerations for Pediatric Asthma Treatment

• Inhaled corticosteroids are the preferred long-term control medication for initiating therapy in children under 12 years with asthma 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, few studies are available on step-up therapy in this age group, and the studies have mixed findings 1.
• Adding a noncorticosteroid long-term control medication to medium-dose ICS may be considered before increasing the dose of ICS to high-dose to avoid potential risk of side effects with high doses of medication 1.

Monitoring Response to Therapy

• Monitor response to therapy closely, because treatment of young children is often in the form of a therapeutic trial 1.
• If a clear and beneficial response is not obvious within 4 to 6 weeks and the patient’s/family’s medication technique and adherence are satisfactory, treatment should be stopped 1.
• If a clear and beneficial response is sustained for at least 3 months, consider a step down to evaluate the need for continued daily long-term control therapy 1.

While the PACT study provides evidence for the effectiveness of low-dose ICS in treating children with mild-to-moderate persistent asthma 1, the recommendations for pediatric asthma treatment should prioritize the use of ICS as the preferred long-term control medication, with consideration of individual patient factors and response to therapy 1.

From the Research

Maintenance and Reliever Therapy (MART) for Asthma in Pediatrics

• The American College of Allergy, Asthma, & Immunology recommends adding a long-acting beta-2 agonist to inhaled corticosteroids (ICS) for children older than 5 years with asthma who remain symptomatic despite ICS therapy 2.
• A study comparing the efficacy and safety of doubling the dose of ICS with adding a long-acting beta-2 agonist to ICS in children with uncontrolled asthma found that adding a long-acting beta-2 agonist was more effective than doubling the ICS dose 3.
• The safety profile of fluticasone propionate-salmeterol was similar to that of fluticasone propionate alone in children with persistent asthma 2.
• Inhaled corticosteroids are the preferred primary long-term treatment for asthmatic children of all age groups, but leukotriene receptor antagonists can be considered as an alternative treatment for mild persistent asthma 4.
• Fluticasone propionate/salmeterol is an effective option for the management of moderate-to-severe asthma in the pediatric population, with improvements in asthma outcomes, including reduced risk of asthma-related emergency department visits and hospitalizations, and improvements in measures of lung function 5.
• For children with uncontrolled asthma despite the use of low-dose inhaled corticosteroids, step-up therapy with a long-acting beta-agonist is more likely to provide the best response than either increasing the dose of inhaled corticosteroids or adding a leukotriene-receptor antagonist 6.

Key Findings

• Adding a long-acting beta-2 agonist to ICS is a preferred controller option for children older than 4 years with symptomatic asthma 3, 2.
• Fluticasone propionate-salmeterol is well tolerated and has a similar safety profile to fluticasone propionate alone in children with persistent asthma 2.
• Inhaled corticosteroids are the preferred primary long-term treatment for asthmatic children of all age groups 4.
• Fluticasone propionate/salmeterol provides an effective option for the management of moderate-to-severe asthma in the pediatric population 5.
• Step-up therapy with a long-acting beta-agonist is more likely to provide the best response than either increasing the dose of inhaled corticosteroids or adding a leukotriene-receptor antagonist for children with uncontrolled asthma despite the use of low-dose inhaled corticosteroids 6.