March 17, 2010 - What's the next step when a child's regular steroid inhaler
fails to prevent asthma attacks? Different kids do best with different step-up
treatments, a study funded by the National Institutes of Health
The drugs with the best chance of success -- 45% -- are long-acting
beta-agonists (LABAs), the study suggests. But
safety concerns limit the use of these agents, the best known of which are
Serevent and Foradil and the combination products Advair and
About 30% of kids, the study found, do best either with a
leukotriene-receptor antagonist (LTRA, brands include Accolate, Singulair, and
Zyflo) or by doubling the dose of the child's current inhaled steroid
"Nearly all the children had a differential response to each step-up
therapy," found University of Wisconsin researcher Robert F. Lemanske Jr., MD,
The study enrolled 182 children age 6 to 17 years. All had recent asthma
attacks despite using a steroid inhaler twice a day.
For three 16-week periods, each child continued on his or her baseline dose
of inhaled corticosteroid and tried a different step-up treatment
-- a LABA (Advair), a LTRA (Singulair), or a double dose of their steroid
The bottom line: No clear winner. Moreover, there were few clues to predict
which kids were most likely to do best on which step-up treatment. The few
clues to emerge:
Hispanic and non-Hispanic white children were most likely to have the best
response to LABA and least likely to have the best response to doubling inhaled
Black children were equally likely to have the best response to LABA or
doubling inhaled steroids and less likely to have the best response to
Children who did not have eczema were most likely to have the best response
But neither age, sex, year-long allergies, lung function, previous use or
nonuse of inhaled steroids, number of days asthma was under control before step-up treatment, or
number of recent asthma attacks predicted which step-up treatment would work
What Should Parents Do?
Advice to parents and doctors comes in an editorial by Erika von Mutius, MD,
of University Children's Hospital, Munich; and Jeffrey M. Drazen, MD, editor of
the New England Journal of Medicine.
Von Mutius and Drazen argue that the choice of step-up therapy should be
based first on safety, second on price, and third on convenience.
"Since we still have lingering concerns about the safety of LABAs in the
treatment of asthma, in that they may promote severe exacerbations or fatal
asthmatic events ... our first choice would be either increasing the dose of an
inhaled corticosteroid or adding an LTRA to the therapeutic regimen," they
But whichever treatment a child's parent and doctor choose, von Mutius and
Drazen stress the need for the doctor to stay in close touch with the child to
make sure the chosen treatment truly works.
"For the patient whose asthma is hard to control, there is simply no
substitute for attentive individual follow-up," they insist.
The Lemanske study and the von Mutius editorial appear in the March 18 issue
of the New England Journal of Medicine.
The Lamanske study was funded by a grant from the NIH-sponsored Childhood
Asthma Research and Education (CARE) Network. Study medications were donated by
GlaxoSmithKline and Merck. Several of the study authors declare receiving
consulting fees, lecture fees, and/or grants from various drug companies that
make asthma medications. Von Mutius and Drazen declare no such interests.