New Pediatric Asthma Study Adds to Case Against Boosted ICS

The argument against increased doses of inhaled steroids for pediatric patients with asthma continues to grow.

Earlier this month, a study funded by the National Heart, Lung, and Blood Institute tracked 250-plus children with mild to moderate asthma found no statistically significant improvement in asthma flare-ups between those on a higher or lower dosage of inhaled corticosteroids (ICS). It joined a litany of recent research that could indicate great change to medical habits practiced by many physicians.

Researchers tracked 254 children between the ages of 5 and 11 with mild to moderate asthma. Each child was on a low maintenance dose of ICS (2 inhalations daily of fluticasone propionate at a dose of 44 μg per inhalation) for 48 weeks.

At the first sign of exacerbation, half of the group was switched to a higher dose of 220 μg per inhalation, still twice daily, for 7 days. The remaining half continued on the low-dose regimen.

Daniel J. Jackson, MD, the lead author and an associate professor pediatrics at the University of Wisconsin, noted that previous studies found no help in doubling ICS dosage, so researchers wanted to access “whether larger increases in ICS dose in children taking ICS regularly could prevent severe asthma exacerbations.”

Overall, the children receiving the higher doses during exacerbation episodes ended up with 14% more exposure to the medication, on average, compared to the low-dose group. Yet, there was no statistically significant difference in the number of flare ups experienced by patients in the low-dose group and those in the high-dose group. The study also showed no significant difference in the length of time between initial symptoms and flare up, the overall number of symptoms, or the rates of usage of the rescue drug albuterol during moderate “yellow-zone” episodes.

“We found that this increase from low to high dose is not effective and think that physicians should not routinely include this approach in asthma action plans in children,” Jackson told MD Magazine. He also noted that eliminating spikes in dosages would also reduce the cost of treatment for these patients.

The findings supplement a 2017 review which found that use of ICS for early stages of asthma in children can be beneficial — when administered judiciously. While intermittent ICS therapy was proven effective for episodic wheezing in that review, it also drove the argument that daily treatment lacks proven benefit. Pediatric asthma treatment guidelines often call for daily ICS therapy, researchers noted — an issue that should be corrected with a call to tailored treatment approaches.

Another 2017 study reported that asthma patients using ICS budesonide and fluticasone are more likely to develop pneumonia.

In an MD Magazine Peer Exchange discussion surrounding the role of ICS therapy for chronic obstructive pulmonary disease and asthma this December, Fernando J. Martinez, MD, said it’s become clear that steroids have become an overused therapy.

“And so, all of us are now in a quandary trying to figure out, if they’re overused, when are we going to use them?” Martinez said. “And, when are we not going to use them?”

Martinez noted it is the responsibility of physicians to personalize combination therapy and approaches, ensuring decisions are based on risk components.

About 6.2 million Americans under the age of 18 have asthma, though the US Centers for Disease Control and Prevention reported last month that the rate of hospitalizations due to asthma attacks has been falling.

The findings were first reported at the 2018 Joint Congress of the American Academy of Allergy, Asthma & Immunology (AAAAI) and the World Allergy Organization (WAO) in Orlando.

The study, “Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations,” was published earlier this month in the New England Journal of Medicine.