Paediatrics in Vienna: Table 1—

Brand, P. L. P.; Ratjen, Félix; Aurora, Paul; Dankert-Roelse, J.E.; Ross-Russell, Robert; Kuehni, Claudia E.; Midulla, Fabio; Hedlin, Gunilla

doi:10.1183/09031936.00198009

Cited by 4 publications

(1 citation statement)

References 89 publications

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“…These strategies should affirm that an appropriate drug delivery device is used, that adherence to treatment is good, and that exposure to environmental triggers is minimised. 10…”

Section: Introductionmentioning

confidence: 99%

Management of severe asthma in children

2010

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Children who are referred to specialist care with asthma that does not respond to treatment (problematic severe asthma) are a heterogeneous group, with substantial morbidity. The evidence base for management is sparse, and is mostly based on data from studies in children with mild and moderate asthma and on extrapolation of data from studies in adults with severe asthma. In many children with severe asthma, the diagnosis is wrong or adherence to treatment is poor. The first step is a detailed diagnostic assessment to exclude an alternative diagnosis ("not asthma at all"), followed by a multidisciplinary approach to exclude comorbidities ("asthma plus") and to assess whether the child has difficult asthma (improves when the basic management needs, such as adherence and inhaler technique, are corrected) or true, therapy-resistant asthma (still symptomatic even when the basic management needs are resolved). In particular, environmental causes of secondary steroid resistance should be identified. An individualised treatment plan should be devised depending on the clinical and pathophysiological characterisation. Licensed therapeutic approaches include high-dose inhaled steroids, the Symbicort maintenance and reliever (SMART) regimen (with budesonide and formoterol fumarate), and anti-IgE therapy. Unlicensed treatments include methotrexate, azathioprine, ciclosporin, and subcutaneous terbutaline infusions. Paediatric data are needed on cytokine-specific monoclonal antibody therapies and bronchial thermoplasty. However, despite the interest in innovative approaches, getting the basics right in children with apparently severe asthma will remain the foundation of management for the foreseeable future.

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“…These strategies should affirm that an appropriate drug delivery device is used, that adherence to treatment is good, and that exposure to environmental triggers is minimised. 10…”

Section: Introductionmentioning

confidence: 99%

Management of severe asthma in children

2010

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Commentaries on ‘Addition of long‐acting beta‐agonists to inhaled corticosteroids for chronic asthma in children’

Turner

Thomas

Lazarus

et al. 2010

Evid.‐Based Child Health

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These are commentaries on a Cochrane review, published in this issue of EBCH, first published as: Ni Chroinin M, Lasserson TJ, Greenstone I, Ducharme FM. Addition of long-acting beta-agonists to inhaled corticosteroids for chronic asthma in children. Commentary by Steve Turner and Mike ThomasChronic childhood asthma is a global public health problem and is the commonest long-term illness amongst children in industrialized societies (1,2). The prevalence of childhood asthma has increased dramatically over the last 30 years, and although it may have leveled off in industrialized countries, a rise continues in many developing countries (3). As no cure or effective primary prevention strategy exists, management is aimed at reducing the current impact of the disease and the risk of future complications, such as exacerbations and progressive impairment in lung function (4). Asthma is defined as 'a chronic inflammatory disorder of the airways . . . inflammation is associated with airways hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing . . . associated with widespread, but variable, airflow obstruction within the lungs that is often reversible either spontaneously or with treatment' (1). As the main pathological features of asthma are airways inflammation and bronchoconstriction, pharmacotherapy centres on anti-inflammatory and bronchodilator medication. The symptoms of asthma are, however, not exclusive and are also associated with lower respiratory tract infection and viral induced wheeze, a recurrent wheezing condition in preschool children; asthma symptoms in young children can cause diagnostic and therapeutic uncertainty.For children diagnosed with asthma whose symptoms are persistent and are present on more than two days a week, initial pharmacological treatment is with low dose inhaled corticosteroids (ICS); this step is effective and known to improve symptom control and reduce the risk of exacerbations (5). Approximately 90% of children in the UK aged 5-12 years who are prescribed ICS receive treatment at low doses (6). However, in one large US trial up to 50% of children receiving low dose ICS treatment alone had episodes of poor control and over one-third had an exacerbation requiring oral corticosteroids over a 48-week study period (7). Clearly some children with asthma require treatment beyond low dose ICS. Current guidelines recommend that the next treatment step after low dose ICS in children aged over 5 years is addition of inhaled long acting B2 agonists (LABA) either as a second inhaler or in a fixed-dose combination inhaler with an ICS (1,8). For individuals in whom the addition of LABA does not result in good asthma control, clinicians can either increase to an intermediate ICS dose or consider other non-steroidal 'add on' treatments, i.e. leukotriene receptor antagonist or theophylline. Although studies in adults support the recommendation to add on LABA to low dose ICS (9),

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