Inhaled corticosteroids for recurrent respiratory symptoms in preschool children in general practice: randomized controlled trial

The safety of long-term use of inhaled corticosteroids in patients with asthma: A systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis was performed to determine the safety of long-term use of ICS in patients with asthma.

METHODS

A systematic search was made of PubMed, Embase, Web of Science, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials (RCTs) on treatment of asthma with ICS, compared with non-ICS treatment (placebo or other active drugs), were reviewed.

RESULTS

Eighty-six RCTs (enrolling 51,538 participants) met the inclusion criteria. Oral or oropharyngeal candidiasis (RR 2.58, 95% CI 2.00 to 3.33), and dysphonia/hoarseness (RR 1.56, 95% CI 1.31 to 1.85) were less frequent in the control group. There was no statistically significant difference in the risk of upper respiratory tract infection, lower respiratory tract infection, influenza, decline in bone mineral density, and fractures between the two groups.

CONCLUSION

In addition to the mild local adverse events, the long-term use of ICS was safe in patients with asthma.

Preschool children with persistent asthmatic symptoms

Asthma is the most common chronic airway disease in children, with more than half the reported cases of persistent asthma starting in children below the age of 3 years. Asthma diagnosis in preschool children has proven to be challenging due to the heterogeneity of the disease, the continuing development of the immune system in such a young population, and lack of diagnostic options such as lung function measurement. Early diagnosis and treatment of asthmatic symptoms will improve patients' quality of life and help reduce disease morbidity. However, validated treatment options are scarce due to paucity of data and lack of conclusive studies in such a young patient population. Adjusting study design and endpoints to capture more reliable data with minimal risk of harm to patients is necessary. This thematic series review outlines the current position on preschool asthma, consolidates the current understanding of risk factors and diagnostic hurdles, and emphasizes the importance of early detection and management to help improve patients' quality of life, both present and future. Particular focus was given to anticholinergics and their emerging role in the treatment and control of asthma in pediatric patients.

Inhaled Corticosteroids and Respiratory Infections in Children With Asthma: A Meta-analysis

CONTEXT

Inhaled corticosteroids (ICS) are associated with an increased risk of pneumonia in adult patients with chronic obstructive pulmonary disease.

OBJECTIVE

To assess the association between ICS use and risk of pneumonia and other respiratory infections in children with asthma.

DATA SOURCES

We searched PubMed from inception until May 2015. We also searched clinicaltrials.gov and databases of pharmaceutical manufacturers.

STUDY SELECTION

We selected randomized trials that compared ICS with placebo for at least 4 weeks in children with asthma.

DATA EXTRACTION

We included 39 trials, of which 31 trials with 11 615 patients contributed data to meta-analyses.

RESULTS

The incidence of pneumonia was 0.58% (44/7465) in the ICS group and 1.51% (63/4150) in the placebo group. The meta-analysis of 9 trials that revealed at least 1 event of pneumonia revealed a reduced risk of pneumonia in patients taking ICS (risk ratio [RR]: 0.65; 95% confidence interval [CI]: 0.44 to 0.94). Using risk difference as effect measure, the meta-analysis including all 31 trials revealed no significant difference in the risk of pneumonia between the ICS and placebo groups (risk difference: -0.1%; 95% CI: -0.3% to 0.2%). No significant association was found between ICS and risk of pharyngitis (RR: 1.01; 95% CI: 0.87 to 1.18), otitis media (RR: 1.07; 95% CI: 0.83 to 1.37), and sinusitis (RR: 0.89; 95% CI: 0.76 to 1.05).

LIMITATIONS

Lack of clearly defined criteria for respiratory infections and possible publication bias.

CONCLUSIONS

Regular use of ICS may not increase the risk of pneumonia or other respiratory infections in children with asthma.

An official American Thoracic Society workshop report: optimal lung function tests for monitoring cystic fibrosis, bronchopulmonary dysplasia, and recurrent wheezing in children less than 6 years of age

Although pulmonary function testing plays a key role in the diagnosis and management of chronic pulmonary conditions in children under 6 years of age, objective physiologic assessment is limited in the clinical care of infants and children less than 6 years old, due to the challenges of measuring lung function in this age range. Ongoing research in lung function testing in infants, toddlers, and preschoolers has resulted in techniques that show promise as safe, feasible, and potentially clinically useful tests. Official American Thoracic Society workshops were convened in 2009 and 2010 to review six lung function tests based on a comprehensive review of the literature (infant raised-volume rapid thoracic compression and plethysmography, preschool spirometry, specific airway resistance, forced oscillation, the interrupter technique, and multiple-breath washout). In these proceedings, the current state of the art for each of these tests is reviewed as it applies to the clinical management of infants and children under 6 years of age with cystic fibrosis, bronchopulmonary dysplasia, and recurrent wheeze, using a standardized format that allows easy comparison between the measures. Although insufficient evidence exists to recommend incorporation of these tests into the routine diagnostic evaluation and clinical monitoring of infants and young children with cystic fibrosis, bronchopulmonary dysplasia, or recurrent wheeze, they may be valuable tools with which to address specific concerns, such as ongoing symptoms or monitoring response to treatment, and as outcome measures in clinical research studies.

Symptoms, but not a biomarker response to inhaled corticosteroids, predict asthma in preschool children with recurrent wheeze

Background. A reliable asthma diagnosis is challenging in preschool wheezing children. As inhaled corticosteroids (ICS) are more effective in asthmatics than in children with transient wheeze, an ICS response might be helpful in early asthma diagnosis. Methods. 175 children (aged two–four years) with recurrent wheeze received 200 μg Beclomethasone extra-fine daily for eight weeks. Changes in Exhaled Breath Condensate (EBC) biomarkers (pH, interleukin (IL)-1α, IL-2, IL-4, IL-5, IL-10, IFN-γ, sICAM, and CCL-11), Fractional exhaled Nitric Oxide (FeNO), airway resistance, and symptoms were assessed. At six years of age a child was diagnosed as transient wheezer or asthmatic. Adjusted logistic regression analysis was performed with multiple testing correction. Results. 106 transient wheezers and 64 asthmatics were analysed at six years of age. Neither changes in EBC biomarkers, nor FeNO, airway resistance, or symptoms during ICS trial at preschool age were related to asthma diagnosis at six years of age. However, asthmatics had more airway symptoms before the start of the ICS trial than transient wheezers (P < 0.01). Discussion. Although symptom score in preschool wheezing children at baseline was associated with asthma at six years of age, EBC biomarkers, airway resistance, or symptom response to ICS at preschool age could not predict asthma diagnosis at six years of age.

Ciclesonide in wheezy preschool children with a positive asthma predictive index or atopy

BACKGROUND

Few large-scale studies have examined inhaled corticosteroid treatment in preschool children with recurrent wheeze. We assessed the effects of ciclesonide in preschool children with recurrent wheeze.

METHODS

We included children 2-6 yrs with recurrent wheeze and a positive asthma predictive index or aeroallergen sensitization to, excluding patients with episodic viral wheezing. After a 2-4-week baseline period, patients with ongoing symptoms or rescue medication use were randomised to once-daily ciclesonide 40, 80, 160 μg or placebo for 24 weeks.

RESULTS

The number of wheeze exacerbations requiring systemic corticosteroids was unexpectedly low in all groups: 25 (10.2%) in placebo group, as compared to 11 (4.4%), 18 (7.3%), and 17 (6.7%) in ciclesonide 40, 80, and 160 μg, respectively. The difference in time to first exacerbation was not significantly different between groups (p = 0.786), but the difference in exacerbation rates between placebo and the pooled ciclesonide groups was (p = 0.03). Large and significant (p < 0.0001) improvements in symptom scores and rescue medication use occurred in all groups, including placebo. Improvements in FEV(1) and FEF(25-75) (measured in 284 4-6 yr olds) were larger in the ciclesonide than in the placebo group. No differences in safety parameters (adverse events, height growth, serum and urinary cortisol levels) between ciclesonide and placebo were observed.

CONCLUSIONS

In preschool children with recurrent wheeze and a positive asthma predictive index, ciclesonide modestly reduces wheeze exacerbation rates and improves lung function. A large placebo response and unexpected selection of patients with mild disease may have affected outcomes, highlighting the heterogeneity of preschool wheezing disorders.

Prevalence and risk factors of wheeze in Dutch infants in their first year of life

Factors operating in the first year of life are critical in determining the onset and persistence of wheezing in preschool children. This study was designed to examine the prevalence and risk factors of wheeze in the first year of life in Dutch infants. This was a population-based survey of 13-month-old infants visiting well baby clinics for a scheduled immunization. Parents/caregivers completed a standardized validated questionnaire on respiratory symptoms in the first year of life and putative risk factors. The independent influence of these factors for wheeze was assessed by multiple logistic regression analysis. A total of 1,115 questionnaires were completed. Wheeze ever (with a prevalence in the first year of life of 28.5%) was independently associated with male gender, eczema, sibs with asthma, any allergic disease in the family, day care, damp housing, and asphyxia. Recurrent wheeze (prevalence 14.5%) showed independent associations with eczema, sibs with asthma, and day care. In addition to these factors, severe wheeze (prevalence 15.4%) was also associated with premature rupture of membranes during birth, and with damp housing. Wheeze is common during the first year of life, and places a major burden on families and the health care system. Factors associated with wheeze are mainly related to markers of atopic susceptibility, and to exposure to infections. The strongest modifiable risk factor for wheeze in the first year of life is home dampness. Interventions to reduce home dampness to reduce wheeze in infancy should be examined.

Predicting short term response to anti-inflammatory therapy in young children with asthma

BACKGROUND

Currently available anti-inflammatory treatment for young children with asthma includes inhaled corticosteroids (ICS) and the leukotriene receptor antagonist (LTRA) montelukast.

OBJECTIVE

To evaluate potential biomarkers of predicting short-term (6-week) response to ICS and LTRAs in children with asthma.

METHODS

A total of 102 children aged 4 to 7 years with episodic asthma were enrolled in an open labelled single-centre study. Biomarkers and asthma characteristics were evaluated as predictors of treatment. Of 102 patients 45 became symptomatic during observation and were randomised to treatment either to montelukast or fluticasone for 6 weeks.

RESULTS

Forced Expiratory Volume in one second (FEV1) increased with both treatments: FEV1 at randomisation was 90.2% and after therapy 106.8% with fluticasone vs. 90.8% and 103.7% for montelukast, respectively, showing that montelukast and fluticasone were equally effective in this age group (p = 0.44). Strong correlations to a favourable treatment response were pre-bronchodilatory FEV1 (p < 0.001) and airway reversibility (p = 0.04) at time of randomisation. None of the other biomarkers (methacholine testing, exhaled nitric oxide [eNO], presence of allergy, total Immunoglobulin E [IgE], cumulative specific IgE, eosinophils and parental smoking) were predictive.

CONCLUSION

Despite the small sample size and the open-label design, the study suggests that the use of pre-bronchodilatory FEV1 and airway reversibility appears to be a good indicator of short-term anti-inflammatory therapy in young children with asthma.

Anti-inflammatory drug therapy in asthma

Asthma is a disease with chronic inflammation of the airways and and-inflammatory treatment is a logical treatment. Inhaled corticosteroids [ICS] remain the cornerstone of anti-inflammatory therapy in recent international guidelines. Asthma cannot be cured by any medication: if the drug is discontinued, the disease manifestations return. This has been proven at all ages. In preschool children the diagnosis of asthma is difficult to establish. In this heterogeneous group ICS or leukotriene receptor antagonists [LTRA] are just as effective as placebo; in the future it will hopefully be possible to describe characteristics of responders. LTRA are an alternative in mild asthma, especially when mono-triggered viral related wheeze is present. Theophylline is effective and also has bronchodilatory properties, which need to be balanced against the relatively frequent side effects. The working mechanisms of anti-inflammatory asthma medications including ICS, LTRA, cromones, macrolides and theophylline are described.

Effect of inhaled fluticasone on lung function in infants with recurrent wheezing: a randomised controlled trial

BACKGROUND

Inhaled corticosteroids are used to treat infants with troublesome asthma-like symptoms but their effect on the lung function of these young patients is controversial.

MATERIAL AND METHODS

Forty-four infants with recurrent wheezing (more than 3 episodes) and family history of asthma completed this randomised, parallel, double-blind, controlled trial to compare the effect on lung function (main endpoint) of once-daily inhaled fluticasone (375 microg) versus placebo for 3 months. Pulmonary function was measured while infants were asymptomatic, using the raised volume rapid thoracic compression technique (spirometry-like), and values were converted to z-scores.

RESULTS

The fluticasone group showed a significant increase in forced flows, (p < 0.001), a lower number of physician diagnosed wheezing episodes (p < 0.002), and a significant decrease in the parent-reported number of wheezing episodes per month (p < 0.03), as compared to placebo. One third of parents in the placebo group reported a clinical improvement in their infants. There was no significant difference in morning plasma cortisol between groups at entry or discharge.

CONCLUSIONS

We conclude that once-daily treatment with 375 microg fluticasone increased forced flows and controlled symptoms in infants with recurrent wheezing without altering plasma cortisol levels. The spirometry-like technique is a useful tool to objectively assess the efficacy of anti-asthma medications in infants with repeated troublesome asthma-like symptoms.

[Recurrent wheezing in three year-olds: facts and opportunities]

The 3 year-old group of children has an increased incidence and prevalence of recurrent wheezing episodes. There are different subgroups, who give different inflammatory responses to different triggering agents, and subgroups that differ in aetiopathology and immunopathology. Current diagnostic methods (exhaled nitric oxide in multiple breaths, nitric oxide in exhaled air condensate, induced sputum, broncho-alveolar lavage and endo-bronchial biopsy), enable the inflammatory pattern to be identified and to give the most effective and safe treatment. The various therapeutic options for treatment are reviewed, such as inhaled glucocorticoids when the inflammatory phenotype is eosinophilic, and leukotriene receptor antagonists, when the inflammatory phenotype is predominantly neutrophilic. In accordance with the current recommendations, for the diagnosis as well as for the therapy initiated in children of this age, they must be regularly reviewed, so that if the benefit is not clear, the treatment must be stopped and an alternative diagnosis and treatment considered. The start of treatment should be determined depending on the intensity and frequency of the symptoms, with the aim of decreasing morbidity and increasing the quality of life of the patient.

Epidemiology of asthma exacerbations

Exacerbations of asthma sufficient to require urgent medical intervention are often, but not always, associated with viral infection, especially rhinovirus, with significant interaction with allergen sensitization and exposure. Seasonal patterns of exacerbations are seen especially in children, and may be aggravated by lack of adequate maintenance anti-inflammatory drug treatment during the high-risk viral season most well described in the Northern Hemisphere after school return in September. Age and sex differences in the epidemiology of exacerbations remain less than fully explained, but hormonal influences are demonstrable. Frequent exacerbations may be an indication of greater severity of disease, significant comorbidities, or poor compliance with therapy. Recognizing risk factors for exacerbations and implementing appropriate long-term management strategies coupled with improved compliance should reduce morbidity and mortality associated with asthma exacerbations.

Fluticasone or montelukast for preschool children with asthma-like symptoms: Randomized controlled trial

RATIONALE

Beneficial effects of anti-inflammatory therapy such as fluticasone propionate (FP) and montelukast (Mk) have been demonstrated in preschool children with asthma. However, comparative studies are lacking in this age group. Therefore, we conducted a study to evaluate and compare the effect of FP and Mk in preschool children with asthma-like symptoms.

METHODS

In this multicenter, randomized, placebo-controlled, double-blind, double-dummy trial, children aged 2-6 years with asthma-like symptoms were included. In total, 63 children were randomly allocated to receive FP (25), Mk (18) or placebo (20) for 3 months. The primary outcome was the daily symptom score (wheeze, cough, shortness of breath) as recorded by caregivers in a symptom diary card. Secondary endpoints were rescue medication free days, blood eosinophils and lung function (interrupter technique and forced oscillation technique (FOT)).

RESULTS

During the 3 months study period, symptoms improved in all 3 groups, with a statistically significant difference between FP and placebo in favor of the FP group (p=0.021). A significant reduction in circulating eosinophils after 3 months of treatment was found in the Mk group only (p=0.008), which was significantly different from the change found in the placebo group (p=0.045). With the exception of frequency dependence (measured by FOT), which showed a difference between FP and Mk after 3 months of treatment in favor of the FP group (p=0.048), no differences in lung function within or between groups were found.

CONCLUSIONS

In spite of a lack of power, our results suggest that FP has a beneficial effect on symptoms and Mk on blood eosinophil level as compared to placebo. Except for a difference in one lung function parameter after 3 months between FP and Mk in favor of the FP group, this study revealed no differences between FP and Mk.

On reporting results from randomized controlled trials with recurrent events

BACKGROUND

Evidence-based medicine has been advanced by the use of standards for reporting the design and methodology of randomized controlled trials (RCT). Indeed, without this information it is difficult to assess the quality of evidence from an RCT. Although a variety of statistical methods are available for the analysis of recurrent events, reporting the effect of an intervention on outcomes that recur is an area that remains poorly understood in clinical research. The purpose of this paper is to outline guidelines for reporting results from RCTs where the outcome of interest is a recurrent event.

METHODS

We used a simulation study to relate an event process and results from analyses of the gamma-Poisson, independent-increment, conditional, and marginal Cox models. We reviewed the utility of regression models for the rate of a recurrent event by articulating the associated study questions, preenting the risk sets, and interpreting the regression coefficients.

RESULTS

Based on a single data set produced by simulation, we reported and contrasted results from statistical methods for evaluating treatment effect from an RCT with a recurrent outcome. We showed that each model has different study questions, assumptions, risk sets, and rate ratio interpretation, and so inferences should consider the appropriateness of the model for the RCT.

CONCLUSION

Our guidelines for reporting results from an RCT involving a recurrent event suggest that the study question and the objectives of the trial, such as assessing comparable groups and estimating effect size, should determine the statistical methods. The guidelines should allow clinical researchers to report appropriate measures from an RCT for understanding the effect of intervention on the occurrence of a recurrent event.