What are the simple treatment options for pediatric asthma?

From the Guidelines

For pediatric asthma, the most effective simple treatment option is initiating long-term control therapy with low-dose inhaled corticosteroids (ICS) such as fluticasone or budesonide, as they have been shown to reduce impairment and risk of exacerbations in infants and young children. This approach is supported by the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 1. The guidelines recommend ICS as the preferred long-term control medication for initiating therapy in young children, as the benefits of ICS outweigh any concerns about potential risks of a small, nonprogressive reduction in growth velocity or other possible adverse effects.

Key considerations for selecting medications in young children include:

• Asthma treatment for young children has not been studied adequately, and most recommendations are based on limited data and extrapolations from studies in older children and adults 1
• Preferred treatment options are based on individual drug efficacy studies in this age group; comparator trials are not available 1
• The following long-term control medications are FDA-approved for young children: ICS budesonide nebulizer solution (1-8 years of age), ICS fluticasone dry powder inhaler (>4 years of age), LABA salmeterol dry powder inhaler, alone or in combination with ICS (>4 years of age), and LTRA montelukast (chewable tablets, 2-6 years of age; granules, down to 1 year old) 1

The Pediatric Asthma Controller Trial (PACT) study 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 1. The study found that fluticasone propionate (FP) monotherapy resulted in an improvement of asthma control days (ACDs) during the 48 weeks, compared to montelukast monotherapy, and was superior for clinic-measured FEV1/FVC maximum bronchodilator response, and PC20.

Monitoring response to therapy closely is crucial, as 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, treatment should be stopped, and alternative therapies or alternative diagnoses should be considered. 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.

From the FDA Drug Label

In controlled clinical trials, most patients exhibited an onset of improvement in pulmonary function within 5 minutes as determined by FEV1. Published reports of trials in asthmatic children aged 3 years or older have demonstrated significant improvement in either FEV1 or PEFR within 2 to 20 minutes following a single dose of albuterol inhalation solution An increase of 15% or more in baseline FEV1 has been observed in children aged 5 to 11 years up to 6 hours after treatment with doses of 0. 10 mg/kg or higher of albuterol inhalation solution.

The simple treatment options for pediatric asthma include inhalation of albuterol. Albuterol has been shown to produce a significant improvement in pulmonary function in asthmatic children aged 3 years or older, with effects lasting up to 6 hours 2. The recommended dose is 0.10 mg/kg or higher of albuterol inhalation solution. Key benefits include:

• Rapid onset of action: within 5 minutes
• Sustained improvement: up to 6 hours
• Effective in children: aged 3 years or older

From the Research

Simple Treatment Options for Pediatric Asthma

• Inhaled corticosteroids (ICS) are recommended as the preferred daily controller therapy for pediatric asthma, especially for patients with persistent symptoms 3
• A trial of bronchodilator medication, such as short-acting beta-2 agonists (SABA), can show symptomatic improvement and is used to diagnose asthma 3
• Montelukast is approved for children ages ≥ 12 months and is often used for its ease of daily oral dosing, especially for patients who cannot use inhalers 3
• Long-acting beta-2 adrenergic agonists should only be used in combination with an ICS 3
• For acute asthma attacks, rapidly worsening symptoms are usually treated with an inhaled SABA and oral corticosteroids 4

Treatment Approaches

• Regular ICS use may be the most effective treatment for preventing exacerbation and increasing forced expiratory volume in 1 second (FEV1) in children with mild asthma 5
• As-needed (AN) ICS or AN-SABA may be suitable for patients with mild asthma, but regular ICS use may be more effective in preventing exacerbations 5
• Metered dose inhaler (MDI) can be used to treat acute asthma in the Emergency Department, reducing length of stay and admission rates 6

Asthma Management

• Avoidance of triggers, such as second-hand cigarette smoke exposure and allergens, can significantly reduce symptoms 3
• Asthma is classified in accordance with symptom frequency, peak expiratory flow rate (PEFR), FEV1, and atopic versus nonatopic etiology 4
• Treatment is based on severity classification, from intermittent to persistent, and may include inhaled bronchodilators, steroids, and anti-inflammatory medications 4