What is the role of budesonide (budecort) in treating acute asthma exacerbations in pediatric patients?

Role of Budesonide (Budecort) in Treating Acute Asthma Exacerbations in Pediatric Patients

Budesonide inhalation suspension is indicated for maintenance treatment of asthma in children 12 months to 8 years of age but is NOT indicated for the relief of acute bronchospasm or asthma exacerbations. 1

Indications and Efficacy

• Budesonide is an inhaled corticosteroid (ICS) approved for long-term maintenance treatment and prophylactic therapy in children 12 months to 8 years of age 1
• It helps reduce swelling and inflammation in the lungs, keeping airways open to reduce asthma symptoms, but is not designed to treat sudden symptoms of an asthma attack 1
• For acute asthma exacerbations, short-acting beta2-agonists remain the drugs of choice 2

Evidence for Budesonide in Acute Exacerbations

• Only one guideline mentioned inhaled budesonide for asthma exacerbations, but did not specify the severity level for which it should be used 2
• Some guidelines explicitly discourage the use of inhaled corticosteroids for acute exacerbations, including South African and Indian guidelines 2
• In contrast, Swiss guidelines suggest ICS use for both mild and moderate exacerbations 2
• A small study from 1999 showed that aerosolized budesonide (400 mcg via MDI with spacer) given early in emergency room treatment of moderate asthma exacerbations, along with nebulized salbutamol, helped in early recovery and decreased need for hospitalization 3
• However, a Cochrane review found that inhaled or nebulized corticosteroids cannot be recommended as equivalent to systemic steroids for hospitalized children with acute asthma 4

Recommended Treatment Approach for Acute Asthma Exacerbations

• Systemic corticosteroids (oral, IV) are the recommended treatment for moderate to severe asthma exacerbations 2
• Oral corticosteroids are suggested for mild (5 guidelines), moderate (11 guidelines), and severe exacerbations (4 guidelines) 2
• Intravenous corticosteroids are recommended for severe exacerbations (7 guidelines) and moderate exacerbations (2 guidelines) 2
• Short-acting beta2-agonists and oxygen supplementation are the mainstay of immediate treatment for acute exacerbations 2

Long-term Safety of Budesonide in Children

• Strong evidence from clinical trials following children for up to 6 years suggests that the use of inhaled corticosteroids at recommended doses does not have long-term, clinically significant, or irreversible adverse effects 2
• The CAMP study firmly established the safety of inhaled corticosteroid use in children 2
• Potential side effects to monitor include:
  • Reduced growth velocity (though this effect may be transient) 2, 5
  • Risk of adrenal suppression 1
  • Potential for ocular effects with long-term use 1
  • Decreased bone mineral density in susceptible individuals 1

Practical Considerations

• Budesonide inhalation suspension should only be used with a jet nebulizer connected to an air compressor, not with an ultrasonic nebulizer 1
• For children under 4 years, delivery should be through a face mask that fits snugly over nose and mouth 2
• Always have a short-acting beta2-agonist (rescue inhaler) available to treat sudden symptoms of an asthma attack 1
• Wash the child's face after each treatment to prevent local side effects 2

Conclusion

While budesonide is a valuable medication for long-term asthma control in children, its role in acute exacerbations is limited. For acute asthma attacks, short-acting beta2-agonists, systemic corticosteroids, and oxygen remain the standard of care. Budesonide should be used as maintenance therapy to prevent exacerbations rather than to treat them once they occur.