Title: Treatment of mild persistent asthma in children – Authors' reply
Abstract: We agree with Paul Brand that the evidence clearly indicates that daily inhaled corticosteroids are the most efficacious treatment for mild persistent asthma, and we stated this in several places in our paper. We also indicated, however, that there is ample evidence to suggest that adherence to such treatment is suboptimal and inconsistent, and a study has shown that it can drop to less than 60% of prescribed days during long-term use in school-age children.1Nikander K Turpeinen M Pelkonen AS Bengtsson T Selroos O Haahtela T True adherence with the Turbuhaler in young children with asthma.Arch Dis Child. 2011; 96: 168-173Crossref PubMed Scopus (32) Google Scholar We also previously showed that a high proportion of children whose asthma was apparently uncontrolled by a combination of inhaled corticosteroids and long-acting β agonists were non-adherent to daily therapy even during a highly controlled run-in for a clinical trial.2Strunk RC Bacharier LB Phillips BR et al.Azithromycin or montelukast as inhaled corticosteroid-sparing agents in moderate-to-severe childhood asthma study.J Allergy Clin Immunol. 2008; 122: 1138-1144Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar This observation prompted us to find a therapeutic step-down approach for mild persistent asthma that would not require daily inhaled corticosteroid use, which is often an obstacle that many patients cannot overcome. We stress again that TREXA was not designed to determine whether rescue inhaled corticosteroid therapy can be used as first-line treatment in children who have not been shown to be responsive to daily inhaled corticosteroids.We are less optimistic than Brand with respect to the long-term growth effects of long-term use of daily inhaled corticosteroids. Brand does not quote the recent follow-up of patients enrolled in the Childhood Asthma Management Program.3Strunk RC Sternberg AL Szefler SJ Zeiger RS Bender B Tonascia J Long-term budesonide or nedocromil treatment, once discontinued, does not alter the course of mild to moderate asthma in children and adolescents.J Pediatr. 2009; 154: 682-687Summary Full Text Full Text PDF PubMed Scopus (80) Google Scholar The decreased mean height noted in the budesonide group relative to the placebo group at the end of that trial (1·1 cm; p=0·005) remained significant (0·9 cm; p=0·01) after an additional 4·8 years of follow-up. Therefore, to conclude that daily inhaled corticosteroids only “reset the growth clock temporarily” might be premature.Mark Levy rightfully points out that, in TREXA, in children on rescue inhaled corticosteroid, 8·5% had treatment failure and 35% exacerbations, but rates for these outcomes in the two groups on daily inhaled corticosteroids were comparable: 2·8–5·6% and 28–31%, respectively. If anything, these results thus indicate that therapeutic approaches that are even more effective than inhaled corticosteroids in preventing asthma exacerbations are urgently needed.4Martinez FD Managing childhood asthma: challenge of preventing exacerbations.Pediatrics. 2009; 123: S146-S150Crossref PubMed Scopus (26) Google ScholarWe agree with Elisa Panontin and Giorgio Longo that better step-down strategies for mild persistent asthma are needed. We disagree, however, with the contention that stopping inhaled corticosteroids abruptly, without a plan to reintroduce them as needed or intermittently, is the better approach: the strategy proposed by Panontin and Longo was tested in our placebo group and resulted in an unacceptable proportion of treatment failures.We declare that we have no conflicts of interest other than those stated in the original paper. We agree with Paul Brand that the evidence clearly indicates that daily inhaled corticosteroids are the most efficacious treatment for mild persistent asthma, and we stated this in several places in our paper. We also indicated, however, that there is ample evidence to suggest that adherence to such treatment is suboptimal and inconsistent, and a study has shown that it can drop to less than 60% of prescribed days during long-term use in school-age children.1Nikander K Turpeinen M Pelkonen AS Bengtsson T Selroos O Haahtela T True adherence with the Turbuhaler in young children with asthma.Arch Dis Child. 2011; 96: 168-173Crossref PubMed Scopus (32) Google Scholar We also previously showed that a high proportion of children whose asthma was apparently uncontrolled by a combination of inhaled corticosteroids and long-acting β agonists were non-adherent to daily therapy even during a highly controlled run-in for a clinical trial.2Strunk RC Bacharier LB Phillips BR et al.Azithromycin or montelukast as inhaled corticosteroid-sparing agents in moderate-to-severe childhood asthma study.J Allergy Clin Immunol. 2008; 122: 1138-1144Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar This observation prompted us to find a therapeutic step-down approach for mild persistent asthma that would not require daily inhaled corticosteroid use, which is often an obstacle that many patients cannot overcome. We stress again that TREXA was not designed to determine whether rescue inhaled corticosteroid therapy can be used as first-line treatment in children who have not been shown to be responsive to daily inhaled corticosteroids. We are less optimistic than Brand with respect to the long-term growth effects of long-term use of daily inhaled corticosteroids. Brand does not quote the recent follow-up of patients enrolled in the Childhood Asthma Management Program.3Strunk RC Sternberg AL Szefler SJ Zeiger RS Bender B Tonascia J Long-term budesonide or nedocromil treatment, once discontinued, does not alter the course of mild to moderate asthma in children and adolescents.J Pediatr. 2009; 154: 682-687Summary Full Text Full Text PDF PubMed Scopus (80) Google Scholar The decreased mean height noted in the budesonide group relative to the placebo group at the end of that trial (1·1 cm; p=0·005) remained significant (0·9 cm; p=0·01) after an additional 4·8 years of follow-up. Therefore, to conclude that daily inhaled corticosteroids only “reset the growth clock temporarily” might be premature. Mark Levy rightfully points out that, in TREXA, in children on rescue inhaled corticosteroid, 8·5% had treatment failure and 35% exacerbations, but rates for these outcomes in the two groups on daily inhaled corticosteroids were comparable: 2·8–5·6% and 28–31%, respectively. If anything, these results thus indicate that therapeutic approaches that are even more effective than inhaled corticosteroids in preventing asthma exacerbations are urgently needed.4Martinez FD Managing childhood asthma: challenge of preventing exacerbations.Pediatrics. 2009; 123: S146-S150Crossref PubMed Scopus (26) Google Scholar We agree with Elisa Panontin and Giorgio Longo that better step-down strategies for mild persistent asthma are needed. We disagree, however, with the contention that stopping inhaled corticosteroids abruptly, without a plan to reintroduce them as needed or intermittently, is the better approach: the strategy proposed by Panontin and Longo was tested in our placebo group and resulted in an unacceptable proportion of treatment failures. We declare that we have no conflicts of interest other than those stated in the original paper. Treatment of mild persistent asthma in childrenFernando Martinez and co-workers (Feb 19, p 650)1 highlight that daily use of inhaled corticosteroids is associated with reduced growth, and that intermittent use of these drugs to control mild persistent asthma avoids such growth impairment. This statement could lead physicians and (parents of) patients to think that daily inhaled corticosteroid treatment is unsafe and stunts growth. I would like to point out that the currently available evidence does not support a clinically relevant effect on long-term growth of inhaled corticosteroid therapy in children. Full-Text PDF Treatment of mild persistent asthma in childrenIn their randomised controlled study of children with mild persistent asthma, Fernando Martinez and colleagues1 show that regular inhaled steroids plus use of combined inhaled steroids plus salbutamol for rescue use is best at reducing and preventing excacerbations (measured by treatment failure). They conclude that “the most effective treatment to prevent exacerbations is daily inhaled corticosteroids”. However they, and in his accompanying Comment, William Checkley,2 imply that inhaled corticosteroids as rescue medication with albuterol/salbutamol might be useful for treating these children. Full-Text PDF Treatment of mild persistent asthma in childrenFernando Martinez and colleagues1 report the use of rescue inhaled corticosteroids plus salbutamol in mild persistent asthma. We agree with them as regards the necessity of minimising treatment with inhaled corticosteroids, but we would like to focus on step-down therapy. Full-Text PDF
Publication Year: 2011
Publication Date: 2011-05-01
Language: en
Type: article
Indexed In: ['crossref']
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