Can Symbicort (budesonide/formoterol) be used in a 9-year-old male (YOM) with ongoing mild asthma symptoms who is already on Qvar (beclomethasone)?

Using Symbicort in a 9-Year-Old with Ongoing Mild Asthma Symptoms on Qvar

Symbicort (budesonide/formoterol) should not be used in a 9-year-old with mild asthma symptoms who is already on Qvar (beclomethasone), as this would constitute inappropriate step-up therapy for mild persistent asthma in this age group. 1

Current Treatment Guidelines for Children with Mild Persistent Asthma

• For children with mild persistent asthma (Step 2), the preferred initial controller medication is low-dose inhaled corticosteroid (ICS) such as Qvar 1
• If asthma symptoms persist despite appropriate use of low-dose ICS, the next step in therapy (Step 3) should be considered 1
• For children under 12 years old with inadequate control on low-dose ICS, the preferred step-up option is to increase to medium-dose ICS rather than adding a long-acting beta-agonist (LABA) 1

Concerns with Symbicort in Children Under 12

• Symbicort contains formoterol, a long-acting beta-agonist (LABA), which carries an FDA black box warning regarding increased risk of asthma-related death 2
• The FDA label for Symbicort states: "LABA medicines such as formoterol increase the risk of death from asthma problems" 2
• Combination therapy with ICS-LABA has not been adequately studied in children younger than 12 years of age 1
• The safety profile of LABAs in children under 12 years raises concerns that have not been fully resolved 1

Appropriate Step-Up Options for a 9-Year-Old

• If the child is experiencing ongoing mild symptoms despite appropriate Qvar use, consider these options:

1. Ensure proper inhaler technique and adherence to current Qvar regimen 1
2. Increase to medium-dose Qvar (increase the dose of the current ICS) 1
3. Consider adding a leukotriene receptor antagonist (LTRA) like montelukast as an alternative to increasing ICS dose 1

• Montelukast is approved for children as young as 1 year old and may be particularly beneficial in children with concurrent allergic rhinitis 1

Assessment Before Changing Therapy

• Before stepping up therapy, evaluate:
  • Proper inhaler technique with current Qvar 1
  • Medication adherence 1
  • Environmental trigger control 1
  • Severity and frequency of symptoms 1

Special Considerations for Pediatric Asthma Management

• Children have higher rates of spontaneous symptom remission than adults 1
• Growth should be monitored in children on ICS therapy 1
• The goal is to use the lowest effective dose of medication to maintain control 1

When to Consider Specialist Referral

• If symptoms persist despite appropriate step-up therapy 1
• If there is diagnostic uncertainty 1
• If the child experiences severe exacerbations despite appropriate therapy 1

In conclusion, for a 9-year-old with ongoing mild asthma symptoms on Qvar, the evidence-based approach is to either increase the Qvar dose or add montelukast rather than introducing Symbicort, which contains a LABA that has not been adequately studied in this age group and carries potential safety concerns 1, 2.