What is the recommended initial treatment with Inhaled Corticosteroids (ICS) for a 9-year-old experiencing an asthma flare?

Initial Treatment with Inhaled Corticosteroids for a 9-Year-Old with Asthma Flare

For a 9-year-old experiencing an asthma flare, the recommended initial treatment is daily low-dose inhaled corticosteroids (ICS) with as-needed short-acting beta-agonist (SABA) for quick relief. 1

Initial ICS Dosing Recommendations

• For children 5-11 years old with asthma exacerbation, the preferred treatment approach is to start with low-dose ICS as daily controller therapy along with as-needed SABA for quick relief 1
• The recommended starting dose for a child previously on bronchodilators alone is 0.5 mg once daily or 0.25 mg twice daily of budesonide inhalation suspension 2
• For symptomatic children not responding to non-steroidal therapy, a starting dose of 0.25 mg once daily may be considered 2
• If once-daily treatment does not provide adequate control, the total daily dose should be increased and/or administered as a divided dose 2

Delivery Methods and Administration

• For children of this age, proper inhaler technique is crucial for medication effectiveness 1
• For non-breath-activated metered-dose inhalers (MDIs), use of spacers or valved holding chambers (VHCs) is recommended to reduce local side effects 1
• Advise patients to rinse the mouth (rinse and spit) after inhalation to minimize the risk of oral candidiasis 1
• For budesonide inhalation suspension, administration should be via compressed air-driven jet nebulizers only (not for use with ultrasonic devices) 2

Monitoring Response to Therapy

• Evaluate the response to therapy within 4-6 weeks 1
• If no clear benefit is observed within this timeframe and medication technique and adherence are satisfactory, consider adjusting therapy or alternative diagnoses 1
• Once asthma stability is achieved, titrate the dose downward to the lowest effective dose that maintains control 2
• Monitor growth in children on ICS therapy, as low-dose to medium-dose ICS therapy may be associated with a possible, but not predictable, adverse effect on linear growth (approximately 1 cm) 1

Step-Up Options if Initial Therapy is Insufficient

• If asthma is not well controlled on low-dose ICS, the preferred next step for children 5-11 years is to increase to medium-dose ICS rather than adding a long-acting beta-agonist (LABA) 3
• Before stepping up therapy, evaluate proper inhaler technique, medication adherence, and environmental trigger control 3
• Consider adding a leukotriene receptor antagonist (LTRA) as an alternative to increasing ICS dose 3

Important Considerations and Potential Side Effects

• The potential benefits of ICS outweigh concerns about potential risks of a small, non-progressive reduction in growth velocity or other possible adverse effects 1
• The effect on growth velocity appears to occur in the first several months of treatment and is generally small and not progressive 1
• Poorly controlled asthma may itself delay growth, so appropriate treatment is essential 1
• Use the lowest dose of ICS that maintains asthma control to minimize potential side effects 1

Special Considerations for Asthma Flares

• During an acute flare, SABA should be used as needed for symptoms, with the intensity of treatment depending on severity of symptoms 1
• For moderate to severe exacerbations, systemic corticosteroids may be required in addition to the maintenance ICS 4
• Close monitoring of response to therapy is crucial, especially in children 4

Remember that children have higher rates of spontaneous symptom remission than adults, so regular reassessment of the need for continued therapy is important 3.