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Asthma - Management
Children aged 5-12 years with uncontrolled symptoms on current treatment: How do I manage?

  • Adjust treatment using the step-wise approach outlined below.
  • Before starting a new drug or stepping up treatment, confirm with the parents their understanding of the role of treatment, adherence to treatment, inhaler technique, and appropriate elimination of trigger factors.
  • Choose an effective delivery system on the basis of convenience, cost, and suitability:
    • Step 1: Prescribe a short-acting beta2-agonist to all children with asthma, for rapid symptom relief.
    • Step 2: Consider starting therapy with an inhaled corticosteroid (ICS) at a dose most appropriate to the severity of symptoms; for beclometasone CFC-free as Clenil Modulite® this is 200 to 400 micrograms/day. Indications include:
      • Having symptoms three times weekly or more, or
      • Awakening with symptoms one night a week or more, or
      • Having an exacerbation in the past 2 years, or
      • Using inhaled beta2-agonist three times weekly or more.
    • If ICS therapy is not tolerated, consider starting a leukotriene receptor antagonist or a cromone. Long-acting beta2-agonists (LABA) should only be prescribed with an ICS and therefore should not be considered an alternative to ICS.
    • Step 3: Consider starting Long-acting beta2-agonists (LABA) if symptoms are still uncontrolled when using an ICS at 400 micrograms/day:
      • If the child has a good response to the LABA with adequate symptom control, continue the LABA and current dose of the ICS.
      • If the child has a good response to the LABA but symptom control is still inadequate and the child is receiving 400 micrograms/day of an ICS, continue the LABA and go to step 4.
      • If the child does not respond to LABA, stop the LABA. If symptom control is inadequate and the child is receiving 400 micrograms/day of an ICS, then consider an alternative add-on treatment, such as a leukotriene receptor antagonist or modified-release theophylline, before moving to step 4.
    • Step 4: Consider increasing the ICS to the maximum recommended daily dose. For beclometasone CFC-free as Clenil Modulite® this is 800 micrograms/day.
    • Step 5: Refer to a paediatrician with knowledge of respiratory medicine.
  • Offer self-management education, including written action plans focusing on the individual's needs.
Clarification / Additional information
  • The duration of a trial of add-on therapy depends on the desired outcome. A trial of days to weeks may be sufficient for symptom relief, whilst it may take weeks to months for benefits to be seen in exacerbation rates. For most preventive therapies, improvements begin within days, but the full benefit may only be evident after 3 or 4 months, especially in severe and chronically under-treated disease [GINA, 2006].
  • Short-acting beta2-agonists may be needed on a regular basis to provide temporary relief of uncontrolled symptoms. The aim is to stop the need for reliever medication by using adequate preventive therapy.
  • Inhaled corticosteroids are usually prescribed at the lowest dose needed to achieve control.
  • Inhaled long-acting beta2-agonists: when starting therapy with these drugs, it may be more practical to prescribe separate inhalers to allow titration of doses, and separate inhalers makes it easier to step down treatment if symptoms improve.
  • Leukotriene receptor antagonists may be preferred over modified-release theophylline because they have fewer adverse effects.
  • Oral corticosteroids (daily) are an option for children whose asthma remains inadequately controlled after step 4, but they should not be prescribed without specialist advice.
Basis for recommendation
  • These recommendations are based on the British Guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2009]:
    • For steps 2, 3, and 4, the benefits of treatment in trials are based on improvements in symptoms and lung function, reduced exacerbations, and a good safety profile. The British Thoracic Society based their add-on regimens on extrapolated evidence from trials of add-on therapy to inhaled corticosteroids (ICS) and on previous guidelines. Few clinical trials in specific patient groups are available to guide management.
    • Inhaled corticosteroids (ICS): The evidence suggests that ICS are the most effective preventive treatment for all people with asthma. Nevertheless, there are concerns about local and systemic adverse effects when ICS are used in high doses.
    • Long-acting beta2-agonists (LABA): The evidence suggests that adding a LABA provides better asthma control than increasing ICS above 400 micrograms. In children the dose at which add-on therapy appears to be more beneficial is when ICS exceed 400 micrograms/day (beclometasone equivalent). Use of a LABA alone (without ICS) appears to be associated with increased risk of asthma-related death. Larger prospective studies are needed to confirm these findings.
    • Leukotriene receptor antagonists (LTRA): The evidence suggests that leukotriene receptor antagonists improve asthma symptoms and lung function when added to ICS, but they do not provide greater benefit than increasing ICS alone.
    • Theophylline: The evidence suggests that increasing the ICS dose provides better asthma control than adding in theophylline. Comparison studies with other add-on therapies are limited, but theophylline appears to have a worse adverse effect profile than other drugs.
    • Cromones: Limited and inconclusive evidence suggests that cromones may provide some benefit in controlling asthma symptoms.

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