Reconsidering the Role of Inhaled Steroid for Early Childhood Asthma


Inhaled corticosteroid for wheezing in early childhood is effective in selected patients but does not prevent progression to asthma.

Elissa Abrams, Pulmonology, Asthma, ICS

The effectiveness of inhaled corticosteroid (ICS) for wheezing in early childhood can be increased with judicious use in selected patients, but it has not been found to prevent progression to asthma.

A new review found that ICS is particularly useful in children with atopy or family history of atopy and that some patients can benefit from intermittent treatment rather than the daily administration that is generally recommended in treatment guidelines.

“Due to increasing recognition of the various endotypes and phenotypes of early childhood wheeze, there will likely be an increasing focus on personalized medicine as a means to tailor asthma therapies to the individual child,” Elissa Abrams (pictured), MD, of the department of pediatrics and section of allergy and clinical immunology at the University of Manitoba, in Winnipeg, Canada told MD Magazine.

A common expectation in starting ICS for emerging asthma in a young child, according to Abrams and colleagues, is that it can change the natural history of asthma progression. Several large trials which have used different definitions of allergy risk, however, have not found this to occur. The trials have confirmed that ICS is effective for symptomatic treatment, particularly in those with atopy marked by aeroallergen sensitization and peripheral blood eosinophilia, or history of atopy in the immediate family.

“Toddlers with atopy have the best response to ICS therapy, and atopic toddlers with multi-trigger wheeze should be started on daily ICS therapy,” Abrams said.

Intermittent administration of ICS can be helpful for episodic wheeze, Abrams and colleagues note. Episodic wheeze is typically associated with viral infections, in contrast to wheeze, which emerges from multiple triggers such as irritants, exertion or aeroallergens. Several studies have found daily ICS to be ineffective for episodic wheeze, they indicate, “further strengthening the argument for a cautious and perhaps intermittent approach.”

Although the early use of ICS does not appear to prevent the development of asthma, Abrams and colleagues found compelling data for the potential of other agents. In a study in young children with emerging asthma, the leukotriene receptor antagonist, montelukast (Singulair, Merck), prevented airway remodeling marked by decreased concentrations of exhaled nitic oxide and improved mean airway resistance.

They note that studies with azithromycin have not yet evidenced a long-term disease modifying effect, but indicate “this is certainly possible by reducing the rate of acute lower respiratory tract illnesses or asthma-like exacerbations.”

Abrams and colleagues also reviewed several ongoing studies which are seeking to interrupt asthma development, including with the immunobiologicals, mepolizumab (Nucala, GlaxoSmithKline) and dupilumab (Dupixent, Sanofi and Regeneron), and with interventions to change the bronchial microbiome.

“These efforts will further the goals of identifying children who are most likely to benefit from appropriate treatment while minimizing long-term risk to other children who are less likely to benefit,” Abrams and colleagues concluded.

The review of inhaled corticosteroids and emerging asthma in early childhood was published on-line August 2 in The Lancet Respiratory Medicine.

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