Step-Up Therapy for Poorly Controlled Asthma in Children
Step-Up Therapy for Poorly Controlled Asthma in Children
Study results, favoring long-acting β-agonists, are in tension with a recent FDA advisory.
When asthma in children remains uncontrolled after monotherapy with inhaled corticosteroids (ICS), what is the best next step? Researchers evaluated three step-up therapies in 165 children (age range, 6–17 years) whose asthma was poorly controlled after 2 to 8 weeks of low-dose fluticasone therapy (100 µg twice daily). In a double-blind triple-crossover clinical trial, the children were randomized to receive each of three therapies for 16 weeks: step-up ICS therapy with fluticasone (250 µg twice daily), low-dose fluticasone plus a long-acting β-agonist (LABA step-up; 50 µg daily), and low-dose fluticasone plus a leukotriene-receptor antagonist (LTRA step-up; 5–10 mg daily). The primary outcome was a composite of change in forced expiratory volume in 1 second (FEV1), use of oral steroids, and number of asthma-control days.
Nearly all children — 98% — exhibited improved asthma control. Of the three step-up therapies, LABA afforded the best treatment response (LABA vs. LTRA, 52% vs. 34%; LABA vs. ICS, 54% vs. 32%). Age did not affect response to therapy. Whites and Latinos were most likely to have a best response to add-on LABA and least likely to have a best response to step-up fluticasone. Black children were equally likely to have a best response to LABA and ICS and less likely to have a best response to LTRA.
Abstract and Introduction
Abstract
Study results, favoring long-acting β-agonists, are in tension with a recent FDA advisory.
Introduction
When asthma in children remains uncontrolled after monotherapy with inhaled corticosteroids (ICS), what is the best next step? Researchers evaluated three step-up therapies in 165 children (age range, 6–17 years) whose asthma was poorly controlled after 2 to 8 weeks of low-dose fluticasone therapy (100 µg twice daily). In a double-blind triple-crossover clinical trial, the children were randomized to receive each of three therapies for 16 weeks: step-up ICS therapy with fluticasone (250 µg twice daily), low-dose fluticasone plus a long-acting β-agonist (LABA step-up; 50 µg daily), and low-dose fluticasone plus a leukotriene-receptor antagonist (LTRA step-up; 5–10 mg daily). The primary outcome was a composite of change in forced expiratory volume in 1 second (FEV1), use of oral steroids, and number of asthma-control days.
Nearly all children — 98% — exhibited improved asthma control. Of the three step-up therapies, LABA afforded the best treatment response (LABA vs. LTRA, 52% vs. 34%; LABA vs. ICS, 54% vs. 32%). Age did not affect response to therapy. Whites and Latinos were most likely to have a best response to add-on LABA and least likely to have a best response to step-up fluticasone. Black children were equally likely to have a best response to LABA and ICS and less likely to have a best response to LTRA.
