Can I increase Fluticasone (inhalation corticosteroid) from 125 to 250 mcg for an 11-year-old patient with moderate to severe asthma?

Increasing Fluticasone Dose for Moderate to Severe Asthma in an 11-Year-Old

Yes, increasing fluticasone from 125 mcg to 250 mcg is appropriate for an 11-year-old with moderate to severe asthma that is not well controlled on the current dose. 1

Rationale for Dose Increase

The decision to increase fluticasone dose is supported by several key factors:

• For children 5-11 years old with moderate to severe persistent asthma, medium-dose inhaled corticosteroids (ICS) are recommended when low doses are insufficient to maintain control 1
• According to dosing guidelines, fluticasone 176-352 mcg/day is considered a medium dose for children 4-11 years old 2
• The Expert Panel Report 3 (EPR-3) specifically states that higher doses of ICS may further reduce the risk of exacerbations and are beneficial for patients with more severe asthma 1

Stepwise Approach to Therapy

For an 11-year-old with moderate to severe asthma not controlled on low-dose ICS:

1. Step 2 (Mild Persistent): Low-dose fluticasone (88-176 mcg/day)
2. Step 3 (Moderate Persistent): Medium-dose fluticasone (176-352 mcg/day) OR low-dose fluticasone plus LABA
3. Step 4 (Moderate-Severe Persistent): Medium-dose fluticasone plus LABA 2

Since the patient is already on fluticasone 125 mcg (low dose) and has moderate to severe asthma, increasing to 250 mcg aligns with the recommended step-up approach.

Benefits vs. Risks

Benefits:

• Improved asthma control and lung function
• Reduced risk of exacerbations
• Better symptom management
• Potential to avoid adding a second medication (such as LABA) 1

Risks:

• Potential for growth suppression (though typically small and non-progressive)
• Local side effects (oral candidiasis, pharyngitis, cough) 2
• The EPR-3 guidelines note that "the potential risks of ICSs are well balanced by their benefits" 1

Monitoring Recommendations

After increasing the dose:

• Evaluate response to therapy in 4-6 weeks 1, 2
• Monitor height regularly, as ICS therapy may be associated with a small, non-progressive effect on growth velocity (approximately 1 cm) 1
• Ensure proper inhaler technique to minimize local side effects 1
• Consider adding a spacer/valved holding chamber to reduce local side effects 1
• Advise the patient to rinse mouth after inhalation to reduce risk of oral candidiasis 1

Important Considerations

1. Growth monitoring: While there is a potential for reduced growth velocity with ICS therapy, the EPR-3 guidelines state that "in general, the efficacy of ICSs is sufficient to outweigh any concerns about growth or other systemic effects" 1

2. Alternative approach: If asthma control is not achieved with the increased dose of fluticasone, consider adding a long-acting beta-agonist (LABA) rather than further increasing the ICS dose 1

3. Proper technique: Ensure the child is using proper inhaler technique with a spacer or valved holding chamber to optimize medication delivery 2

4. Titration principle: The guidelines recommend using "the lowest dose of ICS that maintains asthma control" 1, so once control is achieved and maintained for 3 months, consider stepping down therapy

In conclusion, increasing fluticasone from 125 mcg to 250 mcg is an appropriate step in managing moderate to severe asthma in an 11-year-old patient when the lower dose has not provided adequate control.