What is the treatment for severe pediatric asthma?

From the Guidelines

Treatment for severe childhood asthma should prioritize a stepwise approach, starting with high-dose inhaled corticosteroids (fluticasone 500mcg twice daily or equivalent) combined with a long-acting beta-agonist (salmeterol or formoterol) for ongoing management, as recommended by the expert panel report 3 (epr-3) guidelines 1.

Key Considerations

• For acute severe asthma exacerbations, high-dose inhaled short-acting beta-agonists (albuterol/salbutamol 4-8 puffs every 20 minutes for the first hour) via a spacer device or nebulizer (2.5-5mg), along with oral corticosteroids (prednisolone 1-2mg/kg/day, maximum 60mg, for 3-5 days), should be initiated 1.
• Oxygen should be administered to maintain saturation above 92% 1.
• Add-on treatments may include leukotriene receptor antagonists (montelukast 4-5mg daily for ages 6-14, 10mg for older children) 1, tiotropium for children 6 years and older, and in selected cases, biological therapies like omalizumab (anti-IgE) or mepolizumab (anti-IL5) for those with specific inflammatory phenotypes.

Medication Management

• Inhaled corticosteroids are the most consistently effective long-term control medication at all steps of care for persistent asthma, and improve asthma control more effectively in both children and adults than leukotriene receptor antagonists (LTRAs) or any other single, long-term control medication 1.
• Long-acting beta-agonists (LABAs) are not to be used as monotherapy for long-term control of asthma, but can be used in combination with inhaled corticosteroids for long-term control and prevention of symptoms in moderate or severe persistent asthma 1.

Monitoring and Assessment

• Regular assessment of symptom control, lung function, and medication technique is essential to ensure effective management of severe childhood asthma 1.
• An asthma action plan should be provided to caregivers, detailing daily management and how to recognize and respond to worsening symptoms. Some key points to consider when treating severe childhood asthma include:
• The importance of a stepwise approach to treatment, with a focus on high-dose inhaled corticosteroids and long-acting beta-agonists as the backbone of therapy 1.
• The need for regular monitoring and assessment of symptom control, lung function, and medication technique to ensure effective management of severe childhood asthma 1.
• The potential benefits and risks of add-on treatments, such as leukotriene receptor antagonists and biological therapies, and the importance of selecting the most appropriate treatment options for each individual patient 1.

From the FDA Drug Label

The efficacy of SINGULAIR in pediatric patients 6 to 14 years of age was demonstrated in one 8-week, double-blind, placebo-controlled trial in 336 patients (201 treated with SINGULAIR and 135 treated with placebo) using an inhaled β-agonist on an “as-needed” basis Compared with placebo, treatment with one 5-mg SINGULAIR chewable tablet daily resulted in a significant improvement in mean morning FEV1 percent change from baseline (8.7% in the group treated with SINGULAIR vs 4.2% change from baseline in the placebo group, p<0. 001). SINGULAIR, one 5-mg chewable tablet daily at bedtime, significantly decreased the percent of days asthma exacerbations occurred (SINGULAIR 20.6% vs placebo 25.7%, p≤0. 05). The findings of these exploratory efficacy evaluations, along with pharmacokinetics and extrapolation of efficacy data from older patients, support the overall conclusion that SINGULAIR is efficacious in the maintenance treatment of asthma in patients 2 to 5 years of age

Treatment for severe child asthma:

• Montelukast (SINGULAIR) is effective in the maintenance treatment of asthma in patients 2 to 14 years of age.
• The recommended dose is one 5-mg chewable tablet daily at bedtime for patients 6 to 14 years of age.
• For patients 2 to 5 years of age, the efficacy of SINGULAIR is supported by exploratory efficacy evaluations and extrapolation of efficacy data from older patients 2.
• Key benefits of montelukast include significant improvement in FEV1, decrease in asthma exacerbations, and reduction in "as-needed" β-agonist use.

From the Research

Treatment Options for Severe Child Asthma

• Inhaled corticosteroids (ICS) are the recommended treatment for persistent childhood asthma, with any potential small effects on growth considered relatively minor compared to their benefit 3
• Long-acting beta-agonists (LABAs) are a common second-line treatment in people with asthma inadequately controlled with ICS, and can be used in combination with ICS as a maintenance treatment regimen 4, 5, 6
• For severe acute asthma exacerbations, a stepwise approach for escalating therapy may include:
  • Continuous monitoring of cardiorespiratory status via noninvasive or invasive devices
  • Serial clinical examinations and objective scoring of asthma severity
  • Treatment with β-agonists, ipratropium, and steroids (intravenous preferable over oral preparations)
  • Progressive treatment with continuous β-agonists, intravenous magnesium, helium-oxygen mixtures, intravenous terbutaline and/or aminophylline, coupled with high-flow oxygen and non-invasive ventilation 7
• Combination therapies, such as fluticasone/salmeterol and budesonide/formoterol, may be more effective in improving treatment outcomes than monotherapy alone 4, 5
• Newer treatment options, such as tiotropium, anti-immunoglobulin E, and interleukin-5 antibodies, may be considered for certain patients, particularly those aged ≥12 years 3

Stepwise Management of Asthma

• Stepwise management of asthma is recommended for children, with treatment stepped up or stepped down temporarily or long-term based on response over time 3
• Stepping down treatment can maintain symptom control and minimize adverse events while substantially reducing costs 3
• Patient education and better monitoring remain important for self-management and optimum outcomes 3