Step-up therapy for children with asthma

January 01, 0001

Step-up therapy for children with asthma

These US investigators randomly assigned 182 children (6 to 17 years of age), who had uncontrolled asthma while receiving inhaled corticosteroid (ICS, 100 µg of fluticasone twice daily), to receive each of three blinded step-up therapies in random order for 16 weeks: 250 µg of fluticasone twice daily (ICS step-up), 100 µg of fluticasone plus 50 µg of a long-acting beta-agonist twice daily (LABA step-up), or 100 µg of fluticasone twice daily plus 5 or 10 mg of a leukotriene-receptor antagonist daily (LTRA step-up). They used a triple-crossover design and a composite of three outcomes (exacerbations, asthma-control days, and the forced expiratory volume in 1 second) to determine whether the frequency of a differential response to the step-up regimens was more than 25%.

They found: "A differential response occurred in 161 of 165 patients who were evaluated. The response to LABA step-up therapy was most likely to be the best response, as compared with responses to LTRA step-up (relative probability 1.6) and ICS step-up (relative probability 1.7). Higher scores on the Asthma Control Test before randomization (indicating better control at baseline) predicted a better response to LABA step-up. White race predicted a better response to LABA step-up, whereas black patients were least likely to have a best response to LTRA step-up."

The authors concluded: "Nearly all the children had a differential response to each step-up therapy. LABA step-up was significantly more likely to provide the best response than either ICS or LTRA step-up. However, many children had a best response to ICS or LTRA step-up therapy, highlighting the need to regularly monitor and appropriately adjust each child's asthma therapy."

Bottom line seems to be that individuals may have best response to any of the 3 step-up approaches, and the LABA should be tried first since it is most often effective.

For the full abstract, click here.

N Engl J Med 362(11):975-985, 18 March 2010
© 2010 to the Massachusetts Medical Society
Step-up Therapy for Children with Uncontrolled Asthma Receiving Inhaled Corticosteroids. Robert F. Lemanske, David T. Mauger, Christine A. Sorkness, et al. Correspondence to Dr. Lemanske: [email protected]

Category: R Respiratory. Keywords: asthma, children, therapy, step-up, inhaled corticosteroids, fluticasone, leukotriene, long acting beta-agonist, randomized controlled trial, journal watch.
Synopsis edited by Dr Linda French, Toledo, Ohio. Posted on Global Family Doctor 30 March 2010

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