Should QVAR (beclomethasone) be reinitiated in a pediatric patient with reactive airway disease and periodic SABA (short-acting beta-agonist) use, who has wheezing in the right lung fields?

Reinitiation of QVAR for Pediatric Patient with Reactive Airway Disease and Wheezing

Yes, QVAR (beclomethasone) should be reinitiated in this pediatric patient with reactive airway disease who has wheezing in the right lung fields despite reported good control. 1

Assessment of Current Status

• The presence of wheezing on physical examination indicates active airway inflammation and bronchospasm, suggesting that the patient's asthma is not optimally controlled despite the mother's report 1
• Periodic SABA use without controller medication indicates a need for reassessment of the treatment regimen 1
• Wheezing in the right lung fields represents objective evidence of airflow obstruction that requires controller therapy 1

Rationale for Reinitiating QVAR

• According to the National Asthma Education and Prevention Program guidelines, the presence of wheezing on physical examination indicates that the patient's asthma is not well controlled and requires controller medication 1
• Inhaled corticosteroids (ICS) like QVAR are the cornerstone of asthma management for persistent symptoms 1
• Discontinuation of controller therapy in a patient with evidence of active disease increases the risk of exacerbations and poor outcomes 1, 2

Implementation Approach

• Restart QVAR at an age-appropriate dose as the primary controller medication 1, 3
• Continue as-needed SABA for quick-relief therapy of acute symptoms 1
• For children with persistent asthma, daily low-dose ICS with as-needed SABA is recommended as the standard treatment approach 1
• Ensure proper inhaler technique and use of appropriate spacer device for optimal medication delivery 1

Monitoring and Follow-up

• Schedule a follow-up visit within 2-4 weeks to assess response to therapy 1
• Monitor for potential side effects of QVAR, particularly growth velocity in pediatric patients 3
• The FDA label for QVAR notes: "Physicians should closely follow the growth of all pediatric patients taking corticosteroids by any route and weigh the benefits of corticosteroid therapy and asthma control against the possibility of growth suppression" 3

Important Considerations

• Avoid the common pitfall of underestimating asthma severity based solely on parental report without objective assessment 1
• SABA overreliance without controller therapy is associated with poor outcomes and increased risk of exacerbations 4, 2
• The 2020 asthma management guidelines emphasize the importance of controller therapy for patients with persistent symptoms 1
• While QVAR has a different taste and inhalation sensation than CFC-propellant inhalers, it provides effective control with potentially improved lung deposition due to its smaller particle size 5

Alternative Considerations

• For children aged 0-4 years with recurrent wheezing triggered by respiratory infections, a short course of daily ICS at the onset of respiratory infections may be considered 1, 6
• For patients ≥12 years with mild persistent asthma, as-needed concomitant ICS and SABA could be considered as an alternative to daily ICS 1
• For patients with moderate to severe persistent asthma, ICS-formoterol in a single inhaler as both daily controller and reliever therapy may be more effective than separate ICS and SABA 1