The use of inhaled corticosteroids for persistent asthma in infants and young children

Particulate bioaerogels for respiratory drug delivery

The bioaerogel microparticles have been recently developed for respiratory drug delivery and attract fast increasing interests. These highly porous microparticles have ultralow density and hence possess much reduced aerodynamic diameter, which favour them with greatly enhanced dispersibility and improved aerosolisation behaviour. The adjustable particle geometric dimensions by varying preparation methods and controlling operation parameters make it possible to fabricate bioaerogel microparticles with accurate sizes for efficient delivery to the targeted regions of respiratory tract (i.e. intranasal and pulmonary). Additionally, the technical process can provide bioaerogel microparticles with the opportunities of accommodating polar, weak polar and non-polar drugs at sufficient amount to satisfy clinical needs, and the adsorbed drugs are primarily in the amorphous form that potentially can facilitate drug dissolution and improve bioavailability. Finally, the nature of biopolymers can further offer additional advantageous characteristics of improved mucoadhesion, sustained drug release and subsequently elongated time for continuous treatment on-site. These fascinating features strongly support bioaerogel microparticles to become a novel platform for effective delivery of a wide range of drugs to the targeted respiratory regions, with increased drug residence time on-site, sustained drug release, constant treatment for local and systemic diseases and anticipated better-quality of therapeutic effects.

Practice patterns in asthma discharge pharmacotherapy in pediatric emergency departments: a pediatric emergency research Canada study

OBJECTIVES

The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and inhaled corticosteroids (ICS) at discharge in children with acute asthma.

METHODS

This was a retrospective medical record review at six pediatric emergency departments (EDs) of otherwise healthy children 2 to 17 years of age discharged with acute asthma. Data were extracted on history, disease severity, and pharmacotherapy used in the ED and at discharge. The primary outcome was the proportion of children prescribed "comprehensive therapy," i.e., albuterol via metered dose inhaler (MDI) with oral and ICS.

RESULTS

The overall rate of comprehensive therapy was 382 of 654 (58%), which varied from 30% to 84% (p < 0.0001). A total of 570 of 575 children discharged on albuterol received MDIs. Although the rates of prescriptions for oral and ICS were both 80%, only 58% of patients without ICS on arrival were offered ICS at discharge. There was significant variation in the rates of all discharge pharmacotherapies across centers. The independent predictors of comprehensive therapy were daytime presentation (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.05 to 2.67) and "intensive stabilization" (OR = 2.33, 95% CI = 1.29 to 2.67). Seventeen patients (2.6%) were prescribed antibiotics. Children were more likely to receive antibiotics if they had moderate to severe exacerbations (OR = 2.8) or received a chest radiograph (OR = 8.4).

CONCLUSIONS

The overwhelming majority of children discharged from Canadian pediatric EDs with acute asthma are prescribed inhaled albuterol via MDIs. Although the corticosteroid use at discharge is higher than previously reported, utilization of new prescriptions for ICS may not be optimal. Children presenting during daytime to EDs receiving intensive stabilization are more likely to receive the albuterol/oral steroid/ICS combination.

Superiority of nebulized corticosteroids over dry powder inhalers in certain patients with cough variant asthma or cough-predominant asthma

BACKGROUND

The particle distribution might differ between nebulizer therapy and metered-dose inhaler (MDI) or dry powder inhaler (DPI) therapy because the particles repeatedly enter/re-enter the airways with the nebulizer. Inhaled corticosteroids (ICS) were administered with a nebulizer to assess the benefit of changes in the distribution of particles in patients with cough variant asthma (CVA) and cough-predominant asthma (CPA).

METHODS

Patients whose symptoms were not controlled by their current therapy were enrolled. In patients receiving high-dose ICS by MDI or DPI (ICS-MDI/DPI), steroid therapy was switched to 1,320μg/day of nebulized dexamethasone (1,600μg as dexamethasone sodium phosphate) (chronic steroid-independent group). In patients receiving systemic steroids regardless of their ICS-MDI/DPI therapy, nebulized dexamethasone was added and any concurrent ICS-MDI/DPI therapy was halted to detect a steroid-sparing effect (chronic steroid-dependent group). In patients with acute exacerbation of CVA or CPA and persistent symptoms despite systemic corticosteroids, nebulized dexamethasone was added to assess its effect (acute group).

RESULTS

Superior symptom control was achieved in 10 out of 12 steroid-independent patients, 3 out of 6 steroid-dependent patients, and all 7 acute patients.

CONCLUSIONS

Delivery of ICS via a nebulizer has advantages over ICS-MDI/DPI in some patients with CVA or CPA.

Asthma

Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.

Caregiver preferences for pediatric asthma treatment delivery systems

This study was conducted to assess caregiver preferences for pediatric asthma treatment delivery systems. A total of 186 caregivers of children with asthma who ranged in age from 1 to 4 y completed a stated-preference questionnaire to assess the importance of specific treatment attributes in terms of caregivers' preferences, and to determine the percentages of caregivers who preferred specific treatments. Other outcomes assessed included caregivers' likelihood of adhering to pediatric asthma treatment. Most respondents (75%) preferred treatments that have been approved by the US Food and Drug Administration (FDA) in children as young as 12 mo, that require minimal effort in coordination and inhalation on the child's part, and that take up to 10 min to administer. A greater proportion of respondents indicated that they would be able to follow the physician's advice (increased likelihood of adherence) if given this treatment (54%) versus an alternative (35%). This difference did not achieve statistical significance, however. The conjoint analysis method used in this study enabled investigators to assess caregivers' relative preferences for specific attributes of various pediatric asthma treatments. Overall, FDA approval in children as young as 12 mo was the most preferred attribute. Caregiver preference for pediatric asthma treatment alternatives is an important consideration and should be a component of discussions between healthcare professionals and caregivers.

Successful treatment of previously uncontrolled adult asthma with budesonide inhalation suspension: five-year case histories

OBJECTIVE

To determine whether nebulized budesonide inhalation suspension (BIS) is effective in treating adults with asthma that has been uncontrolled by inhaled therapies.

CASE SUMMARIES

Three adults with severe persistent asthma were switched to BIS after poor outcomes with other controller medications, including inhaled corticosteroids (ICSs). BIS dosages were initiated with 1 mg twice daily. Based on physician discretion as symptoms improved, dosages were decreased to 0.5 mg twice daily (2 pts.) or once daily (1 pt.). Patients were instructed to self-manage their asthma, increasing their dosages during periods of asthma worsening. Peak expiratory flow (PEF) was assessed before and after the initiation of BIS. The number of healthcare visits and oral corticosteroid courses recorded in patient medical records during the 3 years before and 5 years after initiation of BIS therapy were compared. In all 3 cases, BIS improved asthma control. BIS consistently increased PEF and reduced the number of urgent care visits and oral corticosteroid courses. All patients reported satisfaction with BIS therapy.

DISCUSSION

Despite proven effectiveness of ICSs for persistent asthma, some patients fail to respond optimally to treatment administered via an inhaler. These 3 case reports suggest that BIS is effective in treating adults with severe persistent asthma who fail to respond optimally to treatment with other ICS preparations. Failure to use inhalers properly, previous poor adherence in 1 case, or patient preference for the nebulizer might explain why nebulized BIS was more effective than other inhaler therapies.

CONCLUSIONS

Switching adults with uncontrolled asthma to BIS therapy may be a valuable treatment option for those who are unable to achieve optimal asthma control, despite asthma education and training on inhaler technique.

Risk of recurrent emergency department visits or hospitalizations in children with asthma receiving nebulized budesonide inhalation suspension compared with other asthma medications

OBJECTIVE

To examine whether nebulized budesonide inhalation suspension treatment reduces asthma-related emergency department visit/hospitalization recurrence risk in children compared with other asthma medications, particularly non-nebulized inhaled corticosteroids.

RESEARCH DESIGN AND METHODS

Longitudinal, retrospective claims analysis of data from a managed care organization database in the United States (July 1, 2000-June 30, 2002). Participants were children aged < or = 8 years with an asthma diagnosis and asthma-related emergency department visit or hospitalization (index event). Asthma medication use, evaluated by asthma-related prescriptions < or = 30 days after the index event, determined treatment groups.

MAIN OUTCOME MEASURE

Emergency department visit/hospitalization recurrence risk from post-index day 31-180 across treatment groups.

RESULTS

Of 10,176 patients with an index event, 13% experienced a post-index recurrence. For patients receiving asthma prescriptions < or = 30 days after the index event, those receiving budesonide inhalation suspension showed a significant reduction in emergency department visit/hospitalization recurrence risk compared with those not prescribed this treatment (adjusted hazard ratio, 0.71; 95% confidence interval, 0.57-0.89). For patients receiving asthma controller medication in the post-index period, those receiving budesonide inhalation suspension had a significantly lower recurrence risk than patients receiving prescriptions for other controller medications (hazard ratio, 0.71; 95% confidence interval, 0.52-0.97). Recurrence risk was significantly reduced (53%) in patients receiving budesonide inhalation suspension prescriptions compared with non-nebulized inhaled corticosteroid prescriptions (hazard ratio, 0.47; 95% confidence interval, 0.28-0.78).

CONCLUSION

For children aged < or = 8 years, budesonide inhalation suspension treatment after an asthma-related emergency department visit/hospitalization was associated with a significantly reduced risk of recurrence compared with other asthma medications and with non-nebulized inhaled corticosteroids. Because this was an observational study, results should be interpreted cautiously. However, this study allowed evaluation of treatment in real-world practice settings not often included in clinical trials.

Paediatric pulmonary drug delivery: considerations in asthma treatment

Aerosol therapy, the preferred route of administration for glucocorticosteroids and short-acting beta(2)-adrenergic agonists in the treatment of paediatric asthma, may be given via nebulisers, metered-dose inhalers and dry powder inhalers. For glucocorticosteroids, therapy with aerosolised medication results in higher concentrations of drug at the target organ with minimal systemic side effects compared with oral treatments. The dose of drug that reaches the airways in children with asthma is dependent on both the delivery device and patient-related factors. Factors that affect aerosol drug delivery are reviewed briefly. Advantages and disadvantages of each device and device-specific factors that influence patient preferences are examined. Although age-based device recommendations have been made, the optimal choice for drug delivery is the one that the patient or caregiver prefers to use, can use correctly and is most likely to use consistently.

The therapy of pre-school wheeze: appropriate and fair?

The current study aimed to assess prevalence and distribution of use of asthma medication for wheeze in pre-school children in the community. We sent a postal questionnaire to the parents of a random population-based sample of 4,277 UK children aged 1-5 years; 3,410 participated (children of south Asian decent were deliberately over-represented). During the previous 12 months, 18% of the children were reported to have received bronchodilators, 8% inhaled corticosteroids (ICS) and 3% oral corticosteroids. Among current wheezers these proportions were 55%, 25%, and 12%, respectively. Use of ICS increased with reported severity of wheeze, but did not reach 60% even in the most severe category. In contrast, 42% of children receiving ICS reported no or very infrequent recent wheeze. Among children with the episodic viral wheeze phenotype, 17% received ICS compared with 40% among multiple-trigger wheezers. Use of ICS by current wheezers was less common in children of South Asian ethnicity and in girls. Although a high proportion of pre-school children in the community used asthma inhalers, treatment seemed to be insufficiently adjusted to severity or phenotype of wheeze, with relative under-treatment of severe wheeze with ICS, especially in girls and South Asian children, but apparent over-treatment of mild and episodic viral wheeze and chronic cough.

Short-term clinical outcomes of acute treatment of childhood asthma

PURPOSE OF REVIEW

Acute exacerbations of asthma are the leading cause of emergency department visits in the pediatric patient. The present review is focused on the identification of those factors that may contribute to improving the short-term outcome of children after discharge from an emergency department visit for acute asthma.

RECENT FINDINGS

Several recent studies have documented that children treated at the emergency department because of an asthma-related event present a high morbidity at 7 and 15 days after discharge, mainly associated with symptom persistence, need for rescue bronchodilator medication, and absenteeism from school or day nursery. A better control of the disease, particularly adequate outpatient follow-up and maintenance treatment with inhaled steroids, could improve short-term clinical outcomes.

SUMMARY

All efforts of emergency room management of children with asthma, identification of severity of the current exacerbation episode, and intensive treatment of the acute asthma attack have usually been directed at reducing the rates of hospitalization and the return for medical care. However, according to reported data on short-term morbidity, it is necessary to define therapeutic and follow-up strategies after treatment for acute asthma and emergency department discharge. Besides standard treatment for an acute asthma exacerbation in a pediatric emergency department, action plans should include a review of the maintenance treatment of asthma to improve underlying disease control and a strong recommendation for close follow-up by the primary care pediatrician.