Annual increase in body mass index in children with asthma on higher doses of inhaled steroids

There is a greater annual increase in body mass index in children with asthma receiving inhaled steroids at a dose > or =400 microg/day (0.5 kg/m2/year; n=100) compared with those receiving < or =200 microg/day (0.1 kg/m2/year; n=98) (P=.0003). This is consistent with an annual increase in body fat in children with asthma receiving > or =400 microg/day of inhaled steroids.     

Effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home

Many clinicians advise their patients to increase the dose of inhaled corticosteroids during acute asthma exacerbations, without strong clinical evidence supporting this treatment. This study investigates the effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home. The study population consisted of children with mild intermittent, mild and moderate persistent asthma aged 1 to 14 years who were treated in our outpatient clinic with inhaled budesonide for 1 year. After participating in an asthma education session, the parents were instructed to initiate treatment with inhaled budesonide at the first signs of asthma exacerbation, starting with 200 to 400 microg budesonide, in combination with beta-2 agonists 4 times a day and followed by a decrease in the dose in 4 to 8 days. Asthma status and peak expiratory flow rates were measured in the 3 monthly follow-up visits. Only children who complied with the treatment regimen and came for follow-up visits regularly were included in the final analysis. One hundred fifty children used our treatment protocol with inhaled budesonide to control their asthma attacks. Clinical improvement of asthma symptoms was achieved after a mean of 1.8 +/- 0.7 days from the beginning of treatment. The parents were able to control 94% of the 1,061 episodes of asthma exacerbation occurring during a cumulative follow-up period of 239 years. In the 3-month period before enrollment, 101 children (67%) had used oral corticosteroids to control their asthma attacks and 50 (33%) were hospitalized. During the entire follow-up period, only 11 children (7%) used oral corticosteroids, and none of the children were hospitalized. The present study demonstrates that children with asthma can control their exacerbations at home using inhaled corticosteroids (budesonide). Treatment, starting with relatively high doses followed by a rapid reduction in dose over 4-8 days, resulted in a decrease in the use of oral steroids and in hospitalization. To achieve good results, patient compliance is essential.     

Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom.

BACKGROUND: Until recently, only two cases of acute adrenal crisis associated with inhaled corticosteroids (ICS) had been reported worldwide. We identified four additional cases and sought to survey the frequency of this side effect in the United Kingdom. METHODS: Questionnaires were sent to all consultant paediatricians and adult endocrinologists registered in a UK medical directory, asking whether they had encountered asthmatic patients with acute adrenal crisis associated with ICS. Those responding positively completed a more detailed questionnaire. Diagnosis was confirmed by symptoms/signs and abnormal hypothalamic-pituitary-adrenal axis function test results. RESULTS: From an initial 2912 questionnaires, 33 patients met the diagnostic criteria (28 children, five adults). Twenty-three children had acute hypoglycaemia (13 with decreased levels of consciousness or coma; nine with coma and convulsions; one with coma, convulsions and death); five had insidious onset of symptoms. Four adults had insidious onset of symptoms; one had hypoglycaemia and convulsions. Of the 33 patients treated with 500-2000 micro g/day ICS, 30 (91%) had received fluticasone, one (3%) fluticasone and budesonide, and two (6%) beclomethasone. CONCLUSIONS: The frequency of acute adrenal crisis was greater than expected as the majority of these patients were treated with ICS doses supported by British Guidelines on Asthma Management. Despite being the least prescribed and most recently introduced ICS, fluticasone was associated with 94% of the cases. We therefore advise that the licensed dosage of fluticasone for children, 400 micro g/day, should not be exceeded unless the patient is being supervised by a physician with experience in problematic asthma. We would also emphasise that until adrenal function has been assessed patients receiving high dose ICS should not have this therapy abruptly terminated as this could precipitate adrenal crisis.     

Current management of allergic asthma in children

Asthma in children is characterized by recurring symptoms such as wheezing, breathlessness, and cough, by airflow obstruction and bronchial hyperresponsiveness, and by underlying inflammation. The presence of allergic sensitization, and allergic rhinitis in particular, is strongly associated with asthma. The goal of management of asthma is to achieve and maintain control of the clinical manifestations of the disease. This can be obtained by drug treatment, education of patients and care givers, and, in allergic asthma, by allergen avoidance and specific immunotherapy. The drugs used in asthma can be classified as controllers - such as inhaled corticosteroids (ICS) and leukotriene receptor antagonists - or relievers (bronchodilators to be used during acute exacerbations of asthma). ICS are the most effective anti-inflammatory controllers for the management of persistent asthma in children of all ages, but there is no consensus about the optimal starting dose. Dose-response studies reported marked and rapid improvement in clinical symptoms and lung function at low doses of ICS, and mild asthma is well controlled by such doses in most children, this ensuring good safety. If there is no improvement with the initial low dose of ICS, an increased ICS dose or additional therapy with leukotriene receptor antagonists or long-acting inhaled β2-agonists should be considered. When asthma is caused by allergy to aeroallergens, specific immunotherapy must be taken into account, in its two forms of subcutaneous or sublingual immunotherapy. The former has complete evidence of efficacy, but the sublingual route is safer and more easily accepted by children.     

吸人糖皮质激素与口服孟鲁司特治疗咳嗽变异型哮喘的疗效比较及随访研究

目的 比较吸入糖皮质激素(ICS)和口服白三烯调节剂(LTM)对儿童咳嗽变异型哮喘(CVA)的疗效,探讨儿童CVA的最佳治疗方案,并探讨CVA发展为典型哮喘的相关危险因素.方法 将84例年龄(3.9±1.2)岁(2～6岁)的CVA患儿随机分为ICS组(42例)和LTM组(42例).ICS组患儿通过定量气雾剂+储雾罐规律吸人二丙酸倍氯米松200 μg/d维持治疗,LTM组患儿每晚口服孟鲁司特5 mg维持治疗,治疗时间6个月,停用试验药物治疗后继续随访18个月.结果 ICS组平均止咳天数为(14±9)d,LTM组平均止咳天数为(13±9)d,两组问比较差异无统计学意义(Z=1.12,P=0.25).在24个月的研究观察期间,ICS组出现喘息的比率(7.1%)明显低于LTM组(33.3%)(x2=8.92,P=0.003).喘息组患儿湿疹和变应性鼻炎的患病率分别为47.1%和58.8%,明显高于无喘息组(分别为19.4%和31.3%)(x2分别为4.16和4.40,P均＜0.05).多因素逐步回归分析结果显示,湿疹和变应性鼻炎是CVA发展为典型哮喘的危险因素,OR值分别为7.668和3.855(P分别为0.002和0.049),而规律吸入ICS是有效的保护因素,其OR值为0.128(P=0.008).结论 CVA患者可转化为典型哮喘,接受ICS治疗的患儿出现喘息的比率低于接受LTM治疗的患儿,湿疹和过敏性鼻炎是CVA发展为典型哮喘的危险因素.     

The effect of asthma and its treatment on growth

Asthma has little, if any, significant effect on attained adult height. Untreated asthma results in a delay of puberty by approximately 1.3 years, and pubertal delay is likely to explain the majority of apparent growth failure in asthmatics. All currently available inhaled corticosteroids (ICS) result in growth suppression at conventional doses (400 microg/day of beclomethasone dipropionate equivalent), but the growth suppressive effects are relatively short lived, after which growth reverts to pretreatment levels. Younger, prepubertal children, appear more sensitive to the growth suppressive effects of ICS. Asthmatic children receiving conventional doses of ICS (400 microg/day of BDP equivalent) will attain an adult height indistinguishable from their predicted adult height (based on their mid parental height), and no different from non-asthmatics. Adult height could possibly be decreased in severe asthmatics, but this is unlikely to be greater than a 1.2 cm decrement. Recent longitudinal studies offer reassurance that at conventional doses ICS do not have significant long term effects on growth, and that their benefits consistently outweigh their side effects.     

That ICS should be first line therapy for asthma--con

Asthma is a heterogeneous disease and it is therefore unrealistic to expect that inhaled corticosteroids (ICS) would be appropriate first line preventer therapy for all children with asthma. There is good theoretical and clinical trial evidence demonstrating that leukotriene receptor antagonists (LTRAs) are more effective than ICS for viral induced wheezing and equivalent to ICS for mild persistent asthma in children. LTRAS do not have the systemic adverse effects of ICS, are generally well tolerated and their once daily oral administration enhances adherence. LTRAs should therefore be first line preventer therapy for children with frequent intermittent or mild persistent asthma while ICS should be reserved as first line treatment for children with moderate to severe persistent asthma. Given the skew in paediatric asthma severity towards the milder end, this effectively means that LTRAs should be tried first in 2 of every 3 children with asthma requiring preventer treatment.     

The effect of asthma and its treatment on growth.

Asthma has little, if any, significant effect on attained adult height. Untreated asthma results in a delay of puberty by approximately 1.3 years, and pubertal delay is likely to explain the majority of apparent growth failure in asthmatics. All currently available inhaled corticosteroids (ICS) result in growth suppression at conventional doses (400 microg/day of beclomethasone dipropionate equivalent), but the growth suppressive effects are relatively short lived, after which growth reverts to pretreatment levels. Younger, prepubertal children, appear more sensitive to the growth suppressive effects of ICS. Asthmatic children receiving conventional doses of ICS (400 microg/day of BDP equivalent) will attain an adult height indistinguishable from their predicted adult height (based on their mid parental height), and no different from non-asthmatics. Adult height could possibly be decreased in severe asthmatics, but this is unlikely to be greater than a 1.2 cm decrement. Recent longitudinal studies offer reassurance that at conventional doses ICS do not have significant long term effects on growth, and that their benefits consistently outweigh their side effects.     

Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom

Background: Until recently, only two cases of acute adrenal crisis associated with inhaled corticosteroids (ICS) had been reported worldwide. We identified four additional cases and sought to survey the frequency of this side effect in the United Kingdom. Methods: Questionnaires were sent to all consultant paediatricians and adult endocrinologists registered in a UK medical directory, asking whether they had encountered asthmatic patients with acute adrenal crisis associated with ICS. Those responding positively completed a more detailed questionnaire. Diagnosis was confirmed by symptoms/signs and abnormal hypothalamic-pituitary-adrenal axis function test results. Results: From an initial 2912 questionnaires, 33 patients met the diagnostic criteria (28 children, five adults). Twenty-three children had acute hypoglycaemia (13 with decreased levels of consciousness or coma; nine with coma and convulsions; one with coma, convulsions and death); five had insidious onset of symptoms. Four adults had insidious onset of symptoms; one had hypoglycaemia and convulsions. Of the 33 patients treated with 500–2000 µg/day ICS, 30 (91%) had received fluticasone, one (3%) fluticasone and budesonide, and two (6%) beclomethasone. Conclusions: The frequency of acute adrenal crisis was greater than expected as the majority of these patients were treated with ICS doses supported by British Guidelines on Asthma Management. Despite being the least prescribed and most recently introduced ICS, fluticasone was associated with 94% of the cases. We therefore advise that the licensed dosage of fluticasone for children, 400 µg/day, should not be exceeded unless the patient is being supervised by a physician with experience in problematic asthma. We would also emphasise that until adrenal function has been assessed patients receiving high dose ICS should not have this therapy abruptly terminated as this could precipitate adrenal crisis.     

Montelukast in pediatric asthma management

Leukotriene modifiers (receptor antagonist and biosynthesis inhibitor) represent the first mediator specific therapeutic option for asthma. Montelukast, a leukotriene receptor antagonist is the only such agent approved for use in pediatric patients. Montelukast modifies action of leukotrienes, which are the most potent bronchoconstrictors, by blocking Cysteinyl leukotriene receptors. Systemic drug like mountelukast can reach lower airways and improves the peripheral functions which play a crucial role in the evolution of asthma. Review of existing literature showed that montelukast compared to placebo has proven clinical efficacy in better control of day time asthma symptoms, percentage of symptom free days, need for rescue drugs and improvement in FEV₁. Studies also demonstrated improvement in airway inflammation as indicated by reduction in fractional exhaled nitric oxide, a marker of inflammation. Studies comparing low dose inhaled corticosteroids (ICS) with montelukast are limited in children and conclude that it is not superior to ICS. For moderate to severe persistent asthma, montelukast has been compared with long acting beta agonists (LABA) as an add-on therapy to ICS, montelukast was less efficacious and less cost-effective. It has beneficial effects in exercise induced asthma and aspirin-sensitive asthma. Montelukast has onset of action within one hour. Patient satisfaction and compliance was better with montelukast than inhaled anti-inflammatory agents due to oral, once a day administration. The recommended doses of montelukast in asthma arechildren 1–5 years: 4 mg chewable tablet, children 6–14 years: 5mg chewable tablet, adults: 10 mg tablet; administered once daily. The drug is well tolerated. Based on the presently available data montelukast may be an alternative treatment for mild persistent asthma as monotherapy where ICS cannot be administered. It is also an alternative to LABA as an add-on therapy to ICS for moderate to severe persistent asthma. The other indications for use of montelukast include: allergic rhinitis, exercise induced bronchoconstriction and aspirin-induced asthma.     

面罩储雾罐经鼻吸入糖皮质激素同步治疗小儿变应性鼻炎并哮喘

目的 探讨采用面罩储雾罐方式给药,经鼻吸入布地奈德(BUD)气雾剂同步治疗小儿变应性鼻炎并哮喘的临床疗效与成本.方法 将72例中～重度变应性鼻炎并轻一中度持续性哮喘的患儿随机分为实验组和对照组,实验组经面罩储雾罐鼻吸入BUD气雾剂400g/d,对照组经口吸入BUD干粉剂400μg/d联合使用BUD鼻喷雾剂256μg/d.进行哮喘和鼻炎的症状评分,监测第1秒时间肺活量(FEV1)、晨起呼气峰流速值(PEF),并进行治疗成本比较.结果 经过12周的临床观察,实验组和对照组的鼻炎症状评分明显下降(F=6.529和7.014,P均<0.01),两组的哮喘症状评分不断减低(F=4.132和4.950,P均<0.01),实验组和对照组的肺通气功能指标PEF(L/min)逐渐升高(F=2.750和3.282,P均<0.05).但两组间的症状评分、FEV1和PEF在入选时与治疗后的多次随访中比较,差异无统计学意义.实验组鼻腔干燥等副反应的发生率(5.6%)低于对照组(19.4%),但差异无统计学意义.平均治疗费用:实验组(244.0±12.8)元,对照组(403.2±17.6)元,差异有统计学意义(P<0.01).结论 面罩式储雾罐经鼻吸入糖皮质激素可同时有效控制小儿变应性鼻炎和哮喘,并有依从性高、副作用少、花费低等优点,适用于轻～中度持续性哮喘合并变应性鼻炎患儿.     

Long-term management of asthma

Long-term management of asthma includes identification and avoidance of precipitating factors of asthma, pharmacotherapy and home management plan. Common precipitating factors include viral upper respiratory infections, exposure to smoke, dust, cold food and cold air. Avoidance of common precipitating factors has been shown to help in better control of asthma. Pharmacotherapy is the main stay of treatment of asthma. Commonly used drugs for better control of asthma are long and short acting bronchodilators, mast cell stabilizers, inhaled steroids, theophylline and steroid sparing agents. After assessment of severity most appropriate medications are selected. For mild episodic asthma the medications are short acting beta agonists as and when required. For mild persistent asthma: as and when required bronchodilators along with a daily maintenance treatment in form of low dose inhaled steroids or cromolyn or oral theophylline or leukotriene antagonists are required. Moderate persistent asthma should be treated with inhaled steroids along with long acting beta agonists for symptom control. For severe persistent asthma the recommended treatment includes inhaled steroids, long acting beta agonists with or without theophylline. If symptoms are not well controlled, a minimal dose of oral prednisolone preferably on alternate days may be needed in few patients. Patients should be followed up every 8–12 weeks. On each follow up visit patients should be examined by a doctor, compliance to medications should be checked and actual inhalation technique is observed. Depending on the assessment, medications may be decreased or stepped up. For exercise induced bronchoconstriction: cromolyn, short or long acting beta agonists or leukotriene antagonists may be used. In children with seasonal asthma, maintenance treatment according to assessed severity should be started 2 weeks in advance and continued throughout the season. These patients should be reassessed after discontinuing the treatment. Parents should be given a written plan for management of acute exacerbation at home     

Acute Bronchial Asthma

Acute asthma is the third commonest cause of pediatric emergency visits at PGIMER. Typically, it presents with acute onset respiratory distress and wheeze in a patient with past or family history of similar episodes. The severity of the acute episode of asthma is judged clinically and categorized as mild, moderate and severe. The initial therapy consists of oxygen, inhaled beta-2 agonists (salbutamol or terbutaline), inhaled budesonide (three doses over 1 h, at 20 min interval) in all and ipratropium bromide and systemic steroids (hydrocortisone or methylprednisolone) in acute severe asthma. Other causes of acute onset wheeze and breathing difficulty such as pneumonia, foreign body, cardiac failure etc. should be ruled out with help of chest radiography and appropriate laboratory investigations in first time wheezers and those not responding to 1 h of inhaled therapy. In case of inadequate response or worsening, intravenous infusion of magnesium sulphate, terbutaline or aminophylline may be used. Magnesium sulphate is the safest and most effective alternative among these. Severe cases may need ICU care and rarely, ventilatory support.     

Eformoterol Turbohaler® compared with salmeterol by dry powder inhaler in asthmatic children not controlled on inhaled corticosteroids

The aim of the study was to compare the efficacy of the inhaled long‐acting β₂‐agonists eformoterol and salmeterol when added to existing inhaled corticosteroid (ICS) therapy in symptomatic asthmatic children. This randomized, 12‐week, parallel‐group study, performed in a primary care setting, included 156 children and adolescents (aged 6–17 years) with moderate persistent asthma. Patients were randomized to open‐label eformoterol (Oxis^®) Turbohaler^® 9 μg (delivered dose) or salmeterol Accuhaler^® 50 μg, both b.i.d, added to current ICS. Assessments included: changes in daytime reliever β₂‐agonist therapy (primary variable), total 24‐h reliever use, lung function, clinic and diary symptom scores, patient and carer health‐related quality of life (HRQL) and adverse events. Daytime reliever use decreased significantly (p < 0.001) from baseline by 65% and 52%, respectively in the eformoterol and salmeterol treatment groups. Compared with salmeterol, eformoterol produced a greater decrease in daytime (?0.46 inhalations/day; p = 0.081) and 24‐h (?0.70 inhalations/day; p = 0.043) reliever use. The percentage of patients who did not require any reliever medication during the study was significantly higher in the eformoterol group (p < 0.05 vs. salmeterol at weeks 8 and 12). Clinic and diary card peak expiratory flow and symptom measures all improved from baseline in both treatment arms. There was a significantly greater effect in favour of eformoterol for the reduction in clinic‐assessed overall night‐time symptoms (p < 0.05 vs. salmeterol). Clinically relevant improvements in patient‐assessed HRQL occurred during treatment with eformoterol and salmeterol, but carer‐assessed HRQL was improved to a clinically relevant extent, only with eformoterol. Both treatments were well tolerated. In children and adolescents with moderate persistent asthma, add‐on therapy with eformoterol was well tolerated and at least as effective as salmeterol.     

Eosinophil cationic protein, myeloperoxidase and tryptase in children with asthma and atopic dermatitis

Serum levels of eosinophil cationic protein (ECP), myeloperoxidase (MPO), tryptase, total IgE and differential blood cell counts were studied in atopic children with: 1) moderate to severe asthma using inhaled steroids and symptom-free for the last 3 weeks (n= 13), 2) mild asthma with sporadic symptoms, using only inhaled β₂-agonists < 3 times/week (n= 15), 3) acute asthmatic attacks admitted to hospital (n= 12), 4) mild to moderate atopic dermatitis (n= 14). Fifteen children without any history of atopy served as controls. ECP, MPO, tryptase and IgE were measured in serum by radioimmunoassays (RIA). The symptom-free children with inhaled steroids had similar median ECP and MPO values as the controls, 8.0 and 360 μg/l, vs. 9.0 and 310 μg/l, while both ECP and MPO were significantly (p < 0.001) increased in the symptom-free children without anti-inflammatory treatment, 32 and 887 μg/l and in those with acute asthma, 28 and 860 μg/l. The children with atopic dermatitis had increased ECP but normal MPO levels, 16.0 and 455 μg/l. Tryptase in serum was not measurable in any patient. All groups except the control group had significantly elevated total IgE levels. The results indicate that in atopic children serum ECP is a good marker of ongoing asthma or atopic dermatitis. The normal levels of ECP and MPO in the children with asthma using inhaled steroids seem to reflect successful anti-inflammatory treatment. The increased levels of ECP and MPO in the children with mild asthma and no anti-inflammatory treatment may indirectly reflect airway inflammation.     

吸入糖皮质激素对支气管哮喘患儿血清基质金属蛋白酶9及基质金属蛋白酶抑制物1的影响

目的 观察吸入糖皮质激素对支气管哮喘(哮喘)患儿血清基质金属蛋白酶9( MMP-9)及基质金属蛋白酶抑制物1( TIMP-1)的影响,探讨糖皮质激素降低呼吸道重塑的机制.方法 哮喘患儿50例.给予糖皮质激素信必可都保(布地奈德/福莫特罗粉吸入剂),每吸含布地奈德80 μg、福莫特罗4.5 μg,每日2次,疗程12周,采用ELISA法测定布地奈德/福莫特罗粉吸入剂吸入前后,血清MMP-9、TIMP-1水平及肺功能指标[第1秒最大呼气量(FEV1)、最大呼气流速峰值(PEF)]的变化,并对二者进行相关性分析.结果 使用吸入糖皮质激素布地奈德/福莫特罗粉剂后,哮喘患儿血清MMP-9水平由吸入前的(43.25±13.26) μg?L-1下降至(29.62±12.47) μ.g? L-1,TIMP-1由吸入前的(119.88±32.56)μg?L-1上升至(143.15±45.36) μg?L-1,差异均有统计学意义(Pa＜0.01).PEF及FEV1变异占预计值百分比分别由吸入前的(76.15±3.26)％,(73.12±4.63)％,上升至(85.42±4.73)％,(86.49±3.72)％,PEF及FEV1变异占预计值百分比与MMP-9/TIMP-1比率均呈负相关(r=-0.402、-0.364,Pa＜0.05).结论 糖皮质激素可通过调节MMP-9/TIMP-1的平衡,降低胶原沉积,从而干预呼吸道重塑的发生.     

Prevalence of hypothalamic-pituitary-adrenal axis suppression in children treated for asthma with inhaled corticosteroid

OBJECTIVE:

To determine the prevalence of hypothalamic-pituitary-adrenal (HPA) axis suppression in asthmatic children on inhaled corticosteroids (ICS).

METHODS:

Clinical and demographic variables were recorded on preconstructed, standardized forms. HPA axis suppression was measured by morning serum cortisol levels and confirmed by low-dose adrenocorticotropic hormone stimulation testing.

RESULTS:

In total, 214 children participated. Twenty children (9.3%, 95% CI 5.3% to 13.4%) had HPA axis suppression. Odds of HPA axis suppression increased with ICS dose (OR 1.005, 95% CI 1.003 to 1.009, P<0.001). All children with HPA axis suppression were on a medium or lower dose of ICS for their age (200 μg/day to 500 μg/day). HPA axis suppression was not predicted by drug type, dose duration, concomitant use of long-acting beta-agonist or nasal steroid, or clinical features.

CONCLUSION:

Laboratory evidence of HPA axis suppression exists in children taking ICS for asthma. Children should be regularly screened for the presence of HPA axis suppression when treated with high-dose ICS (>500 μg/day). Consideration should be given to screening children on medium-dose ICS.     

¿Son eficaces los corticoides inhalados en las exacerbaciones asmáticas? Evidentia praxis

A clinical scenario is presented, from which a structured clinical question arises: In asthmatic children or adolescents with exacerbation symptoms, does the use of inhaled corticosteroids (newly instituted or base dose increased) reduce the risk of exacerbations that require systemic steroids and/or hospitalization? To answer it, we carried out a bibliographic search, with selection, evaluation and graduation of the evidence, following GRADE criteria. We did not find sufficient evidence to consider intermittent inhaled steroids as an alternative to maintenance inhaled steroids to avoid exacerbations that require the use of systemic steroids. The use of a combination of inhaled steroids with formoterol, as a rescue treatment at the onset of symptoms, is only effective when used by patients with this maintenance treatment, compared to those who only have inhaled steroids and rescue with beta2-agonists of short action; when patients already take maintenance combined therapy, combined rescue does not reduce the risk. In patients with asthma attacks attended in the emergency department, inhaled steroids compared to placebo reduce the risk of admission, but not when compared to systemic corticosteroids.     

Long-term management of asthma

Long-term management of asthma includes identification and avoidance of precipitating factors of asthma, pharmacotherapy and home management plan. Common precipitating factors include viral upper respiratory infections, exposure to smoke, dust, cold food and cold air. Avoidance of common precipitating factors has been shown to help in better control of asthma. Pharmacotherapy is the main stay of treatment of asthma. Commonly used drugs for better control of asthma are long and short acting bronchodilators, mast cell stabilizers, inhaled steroids, theophylline and steroid sparing agents. After assessment of severity most appropriate medications are selected. For mild episodic asthma the medications are short acting beta agonists as and when required. For mild persistent asthma: as and when required bronchodilators along with a daily maintenance treatment in form of low dose inhaled steroids or cromolyn or oral theophylline or ketotifen are required. Moderate persistent asthma should be treated with inhaled steroids along with long acting beta agonists for symptom control. For severe persistent asthma the recommended treatment includes inhaled steroids, long acting beta agonists with or without theophylline. If symptoms are not well controlled, a minimal dose of oral prednisolone preferably on alternate days may be needed in few patients. Newer drugs like leukotriene antagonists may find a place in control of exercise-induced bronchoconstriction and mild and moderate persistent asthma. Patients should be followed up every 8-12 weeks. On each follow up visit patients should be examined by a doctor, compliance to medications should be checked and actual inhalation technique is observed. Depending on the assessment, medications may be decreased or stepped up. For exercise induced bronchoconstriction: cromolyn, short or long acting beta agonists may be used. In children with seasonal asthma, maintenance treatment according to assessed severity should be started 2 weeks in advance and continued throughout the season. These patients should be reassessed after discontinuing the treatment. Parents should be given a written plan for management of acute exacerbation at home.