“Step-up” treatments in childhood asthma - which should we choose?

Published online: March 25, 2017

For most asthmatic children their symptoms are controlled with intermittent use of inhaled bronchodilators and/or regular low dose inhaled corticosteroids (ICS). Some children however continue to have symptoms despite these medications and their physician will elect to step up their treatment. Although these “step-up” medications have been available for children for almost 20 years there still remains controversy as to which option is the best. There are few studies comparing one option with another and relatively small numbers of children in trials. A recent meta-analysis of all the trials was also unable to draw any firm conclusions.

In a study recently published in The Journal of Allergy and Clinical Immunology: In Practice, Murray and colleagues compared the effectiveness of step-up therapies from low-dose ICS in a real-life pediatric population. They used historical data from primary care databases (Optimum Patient Care Research Database and Clinical Practice Research Databases) in the United Kingdom (including approximately 15% of UK children). Children (5-12 years) in the database with a diagnosis of asthma who were taking ICS were identified at their first step up of treatment and were included if they had a year of data before and after the step up date in the database.

Eligible children from the increase ICS and LTRA step-up groups were separately matched (1 to 1) on key demographic and asthma-related characteristics during the baseline year to children from the FDC step-up group. Outcomes, including severe asthma exacerbation rate (ATS/ERS definition) and asthma control (no exacerbations and low reliever treatment use), in the following year were then compared between the two matched groups.

Exacerbation rates improved in all children and were similar between the FDC group and the increased ICS group, and between the FDC and the LTRA groups. However, overall asthma control was improved in the FDC group compared with both the increased ICS and the LTRA groups.

Using this real-life dataset resulted in a study considerably larger than even the published met-analysis but its retrospective nature meant that the outcomes reported were not necessarily comparable to those usually reported in prospective randomized controlled trials. The findings of this study suggest that all three “step-up” treatments have beneficial effects in children. All treatments appeared to produce benefits in reducing exacerbation rates in children with asthma. Changing to FDC however, may result in better overall asthma control over LTRA or increased ICS principally driven by lower reliever treatment usage.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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