Feb. 15, 2011 -- Using inhaled steroids as a rescue medicine along with albuterol may help some children with mild persistent asthma avoid daily inhaled steroid therapy and one of its potential side effects, namely growth restriction, according to a new study.
The new findings, which appear in the Lancet, apply only to children with mild persistent asthma that is under control. This step-down treatment is not recommended for children with moderate to severe asthma or uncontrolled mild asthma.
Many children with asthma take one or two puffs of inhaled steroids such as beclomethasone each morning and evening to prevent an asthma attack. They also use a bronchodilator such as albuterol as a rescue medication to treat any breakthrough symptoms. Such symptom relief from albuterol doesn’t get at the underlying airway inflammation, which is why some people need daily inhaled steroids. Daily inhaled steroids are still considered the gold standard to prevent asthma attacks but are not risk-free. Risks of daily inhaled steroid therapy in children include possible restricted growth and problems with adherence.
“The strategy is to give rescue therapy with inhaled corticosteroids every time you need albuterol for relief of symptoms,” says study researcher Fernando D. Martinez, MD, the Swift-McNear Professor of Pediatrics and director of the Arizona Respiratory Center at the University of Arizonain Tucson. Forexample, “you can use two puffs on Monday and another two puffs on Friday during one week, none during another week, and six puffs every day on another week, depending on how many symptoms you have,” he says in an email.
The key is to know when you need help. “If the cold starts causing tightness and shortness of breath, the child will need more albuterol and thus will use more inhaled steroids,” he says. Colds can be an asthma trigger. “The number of inhaled steroid puffs is proportional to how many albuterol puffs are needed, and therefore, to how severe the symptoms are.”
In the study, 288 children aged 6 to 18 with persistent asthma were divided into four groups:
- The “combined group” received twice daily inhaled steroids (beclomethasone) and beclomethasone plus albuterol as a rescue.
- The “daily group” received twice daily beclomethasone and placebo plus albuterol as a rescue.
- The “rescue group” received twice daily placebo therapy and beclomethasone plus albuterol as a rescue.
- The placebo group received twice daily placebo and placebo plus albuterol as a rescue.
Children and adolescents in the daily group had fewer asthma exacerbations (28%) than those in the placebo group (49%).
Treatment failure occurred 23% in the placebo group, compared with 6% in the combined, 3% in the daily group, and 8.5% in the rescue group.
The researchers also looked at growth restriction and found that growth was on average 1.1 centimeter less over the course of the 44-week study period in the combined and daily groups than in the placebo group. There was no difference in growth in the rescue group compared to the placebo group.
More study is needed to confirm the new study findings, Martinez says. “Our results were very suggestive, but statistically borderline and with small numbers,” he says. “A larger definitive study is needed.”
Always Discuss Medication Changes With a Doctor First
“This is some important and landmark work,” says Harold J. Farber, MD, an associate professor of the pediatric pulmonary section at Baylor College of Medicine and Texas Children Hospital in Houston and author of Control Your Child's Asthma.
“Starting the steroid beclomethasone along with albuterol at onset of symptoms gave almost as good of a benefit in prevention as daily inhaled steroid therapy,” he says.
But “for it to work, you have to start it early at first sign of an attack,” he says. “If we wait for severe problems, it’s too little too late.”
This advice is only good for “folks with mild asthma, not folks with moderate to severe asthma,” he says. “If you have moderate to severe asthma, the use of inhaled corticosteroid every day is better than as-needed use.”
“Always talk with your doctor before making any changes to medication,” Farber says.
“When used as a rescue modality, inhaled steroids (beclomethasone) do a reasonable job at controlling symptoms without the side effects of reduced growth,” says William Checkley, MD, assistant professor in the Division of Pulmonary and Critical Care of the Johns Hopkins School of Medicine in Baltimore. “This step-down approach reduces the need to do puffs twice a day.”
But “there have to be more studies to support these findings,” he says. Checkley wrote an editorial accompanying the study.