Growth and bone density in children with mild-moderate asthma: a cross-sectional study in children entering the Childhood Asthma Management Program (CAMP)

Intranasal combo: fixed-dose combination of mometasone furoate and olopatadine hydrochloride in therapeutic strategies for rhinosinusitis

A novel strategy for the treatment of allergic rhinitis results from the innovative combination of antihistamine and intranasal corticosteroid drugs. By combining two preparations with different mechanism of action, this novel approach facilitates quick and effective controls of all upper respiratory tract allergy symptoms. The article presents the results of a study of olopatadine hydrochloride and mometasone furoate fixed-dose combination (GSP301) administered intranasally from a spray formulation, with an attempt at positioning the treatment within the ARIA and EPOS guidelines.

The influence of childhood asthma on adult height: evidence from the UK Biobank

BACKGROUND

To elucidate the influence of childhood asthma on adult height after consideration of genetic heterogeneity in height.

METHODS

Based on the UK Biobank, we conducted a matched cohort study, including 13,602 European individuals with asthma diagnosed before 18 years old and 136,008 matched unexposed individuals without such an experience. Ascertainment of asthma was based on self-reported data (97.6%) or clinical diagnosis in healthcare registers (2.4%). We studied three height outcomes, including (1) the attained adult height (in centimeters), (2) the height deviation measured as the difference between a person's rank of genetically determined height (based on generated polygenetic risk score) and their rank of attained adult height in the study population (deviation in % of height order after standardization), and (3) the presence of height deficit comparing genetically determined and attained height (yes or no). We applied linear mixed-effect models to assess the associations of asthma diagnosed at different ages with attained adult height and height deviation, and conditional logistic regression models to estimate the associations of asthma with the risk of height deficit.

RESULTS

40.07% (59,944/149,610) of the study participants were born before 1950, and most of them were men (57.65%). After controlling for multiple covariates, childhood asthma was associated with shorter attained adult height, irrespective of age at asthma diagnosis. However, in the analysis of height deviation (deviation in %), we observed the greatest height deviation among individuals with asthma diagnosed before 4 years of age (- 2.57 [95% CI - 4.14 to - 1.00] and - 2.80 [95% CI - 4.06 to - 1.54] for the age of ≤ 2 and 3-4 years, respectively). The magnitude of height deviation in relation to asthma declined thereafter and became null after age 6. Similarly, there was a statistically significant height deficit in relation to an asthma diagnosis at ages ≤ 2 and 3-4 (odds ratios = 1.21, 95% CI 1.04 to 1.40, and 1.15, 95% CI 1.02 to 1.29) but not thereafter. The result pattern was similar when separately analyzing asthma with or without inhaled glucocorticoid (ICS) use, despite that the estimates were consistently stronger among asthma individuals who used ICS.

CONCLUSIONS

Our results suggest a notable association of childhood asthma, primarily asthma diagnosed at an early age, with adult height, after consideration of genetic heterogeneity in height and use of ICS. This finding highlights the need for surveillance on the growth problems among children with asthma.

The impact of asthma and its treatment on growth: an evidence-based review

OBJECTIVES

To assess the impact of asthma and its treatment (inhaled corticosteroids and other control medications) on growth.

DATA SOURCES

The authors searched PubMed (up to August 24, 2018) and screened the reference lists of retrieved articles. Systematic reviews and meta-analysis were selected. If there was no such article, the authors selected either randomized clinical trials or observational studies.

DATA SYNTHESIS

A total of 37 articles were included in this review. The findings from 21 studies suggest that asthma per se, especially more severe and/or uncontrolled cases, can transitorily impair child's growth. Two Cochrane reviews of randomized clinical trials showed a small mean reduction in linear growth (-0.91cm/year for beclomethasone, -0.59cm/year for budesonide, and -0.39cm/year for fluticasone) in the first year of treatment with inhaled corticosteroids in prepubertal children with persistent asthma. The effects were likely to be molecule- and dose-dependent. A recent review showed that most of "real-life" observational studies had not found significant effects of inhaled corticosteroids on growth in asthmatic children. Fifteen studies showed that the maintenance systemic corticosteroids could cause a dose-dependent growth suppression in children with severe asthma, but other controllers (cromones, montelukast, salmeterol, and theophylline) had no significant adverse effects no growth.

CONCLUSIONS

Severe and/or uncontrolled asthma can transitorily impair child's growth. Regular use of inhaled corticosteroids may cause a small reduction in linear growth in children with asthma, but the well-established benefits of inhaled corticosteroids in controlling asthma outweigh the potential adverse effects on growth. Use of the minimally effective dose of inhaled corticosteroids and regular monitoring of child's height during inhaled corticosteroids therapy are recommended.

Growth Pattern, Resting Energy Expenditure, and Nutrient Intake of Children with Food Allergies

Growth impairment has been reported in children with food allergies (FA). However, the available data on the dietary intake of FA children are controversial, and no data are available on their resting energy expenditure (REE). The aim of this study was to test whether REE differs between FA and healthy children. In this study, 30 FA children were matched by sex and age, with 31 healthy controls using coarsened exact matching (CEM). Their REE was measured by indirect calorimetry (IC). Energy and macronutrient intake were evaluated using a three-day dietary record. Between-group comparisons were performed by robust median regression using CEM-related weights. The association of REE with allergies was also evaluated using robust median regression models. Anthropometric measurements, REE, and nutrient intake were similar in FA children and matched controls. Taking into account the association of REE with gender and age, a statistically significant but biologically negligible association was detected between median REE and allergy status (+9% in FA children). In conclusion, we did not find any biologically relevant difference in REE, anthropometry, and dietary intake in children with FA compared to healthy children.

Growth and nutritional concerns in children with food allergy

PURPOSE OF REVIEW

To describe the potential effect that avoidance diets for food allergy may have on nutrition and growth in children.

RECENT FINDINGS

We report here the findings from the previous studies suggesting impairment of growth and nutritional deficiencies because of elimination diets for food allergy. Feeding difficulties have also been reported, particularly in children with eosinophilic esophagitis that may further impact the nutrient intake.

SUMMARY

Food allergies are becoming more prevalent and better recognized. Treatment options typically include strict dietary elimination of major food allergens such as milk, eggs, wheat, soy, peanut, tree nuts, fish and shellfish. Monitoring growth and guiding food allergic patients in choosing appropriate alternatives to supply necessary nutrients becomes crucial to avoid deficiencies and retardation in growth.

Advancing asthma care: the glass is only half full!

Over the past 20 years, there has been a concerted effort in the United States to reduce morbidity related to chronic disease, including asthma. Attention was initially directed toward asthma in response to the recognition that asthma mortality was increasing and that the burden of disease was significant. These efforts to address asthma mortality led to many new initiatives to develop clinical practice guidelines, implement the asthma guidelines into clinical practice, conduct research to fill the gaps in the guidelines, and continuously revise the asthma guidelines as more information became available. An assessment of our progress shows significant accomplishments in relation to reducing asthma mortality and hospitalizations. Consequently, we are now at a crossroads in asthma care. Although we have recognized some remarkable accomplishments in reducing asthma mortality and morbidity, the availability of new tools to monitor disease activity, including biomarkers and epigenetic markers, along with information technology systems to monitor asthma control hold some promise in identifying gaps in disease management. These advances should prompt the evolution of new strategies and new treatments to further reduce disease burden. It now becomes imperative to continue a focus on ways to further reduce the burden of asthma and prevent its onset.

Inhaled corticosteroids may have a beneficial effect on bone metabolism in newly diagnosed asthmatic children

BACKGROUND

The adverse effect of inhaled corticosteroids (ICS) treatment on bone metabolism in children with asthma is still controversial, and a possible beneficial effect of vitamin D added to ICS on bone turnover is uncertain.

OBJECTIVE

We conducted a randomized, double-blind, parallel-group, 6-month trial to assess the effects of a medium and high dose of ICS and a high-dose ICS with vitamin D on bone metabolism in children with newly diagnosed atopic asthma.

METHODS

96 children were equally randomized to 4 groups receiving the following doses of inhaled budesonide [μg/day]: 400 (ICS 400 group), 800 (ICS 800 group), 800 with oral vitamin D (ICS 800 with vit D group), and montelukast as a control (control group). Markers of bone production (osteocalcin, alkaline phosphatase) and bone degradation (amino-terminal cross-linked telopeptide of type I collagen--NTx, carboxy-terminal telopeptides of type I collage), and also concentration of 25-hydroxycholecalciferol (25OH D) and calcium-phosphorus balance (calcium, phosphorus, parathormon-PTH) in serum and/or urine were assessed twice: before and after 6 months of treatment.

RESULTS

We obtained a significant decrease in phosphorus and PTH serum levels in ICS 400 and ICS 800 with vit D groups compared to control group, and a significant decrease of NTx urine level in ICS 800 with vit D group.

CONCLUSIONS

Medium doses of inhaled corticosteroids exert an advantageous effect on bone metabolism in newly diagnosed asthmatic children. Vitamin D together with a high dose of inhaled corticosteroids has a beneficial effect on both calcium-phosphorus balance and collagen turnover.

Bone mineral density in children treated with daily or periodical inhaled budesonide: the Helsinki Early Intervention Childhood Asthma study

In a double-blind, randomized study, 136 children, 5-10-y-old, with newly detected persistent asthma received budesonide (BUD) 400 microg twice daily for 1 mo and thereafter 200 microg twice daily for 5 mo. Thereafter, 50 children were treated with BUD 100 microg twice daily, whereas 44 children used BUD as needed for 1 y; an additional 42 children received disodium cromoglycate (DSCG). Asthma exacerbations were treated with BUD for 2 wk in a dose of 400 microg twice daily in all groups. In this secondary analysis, bone mineral density (BMD) of the lumbar vertebrae was measured before and after the 18-mo treatment. Compared with DSCG, regular BUD treatment resulted in a significantly smaller increase in BMD (0.023 versus 0.034 g/cm; p = 0.023) and height (7.75 versus 8.80 cm; p = 0.001). Periodic treatment did not affect BMD. No intergroup differences were observed when BMD data were adjusted for changes in height. Daily BUD treatment in prepubertal children may slow down the increment in BMD and standing height. This was not observed in children receiving BUD periodically after the initial regular BUD treatment. The correlation between height and BMD suggests that following children's height might afford an estimation of inhaled corticosteroid effects on bone.

Recent advances in pediatric asthma treatment

Although wheezing illness is at its most prevalent in infancy and early childhood, its self-limiting nature in the majority poses considerable challenges in offering a long-term prognosis and in initiating long-term prophylaxis. Many of the established treatments in adults have not been adequately assessed in children. Evidence is also emerging for a number of different wheezing syndromes, several of which do not to respond well to currently available medicines. Much research interest is being directed to underlying changes within the airway that appear to be independent of allergic mechanisms and that may lead to novel therapeutic approaches. The aim of this review is to restate and update current best-practice based on evidence, to encourage effective and safe use of asthma medication in children and to point to areas of ongoing research that are likely to influence management decisions in the near future.

Effects of inhaled steroids on growth, bone metabolism and adrenal function

Inhaled corticosteroids are a first-line therapy for persistent asthma in children. Major safety concerns of long-term inhaled corticosteroid therapy include suppression of adrenal function, growth and bone development. Proper interpretation of inhaled corticosteroid safety studies requires knowledge of the differences among various inhaled corticosteroid drug/delivery device systems. Dosage, type of inhaler device used, patient technique and characteristics of the individual drug influence the systemic effects of inhaled corticosteroids. Systemic side effects can occur when continuous high-dose treatment is required for severe asthma or when the dosage prescribed is excessive and compliance unusually good. Overall, however, recent studies confirm that benefits of inhaled corticosteroids, properly prescribed and used, clearly outweigh not only their potential adverse effects, but also the risks associated with poorly controlled asthma.

Therapeutic management of allergic diseases

Allergic diseases are characterized by the activation of inflammatory cells and by a massive release of mediators. The aim of this chapter was to describe succinctly the modes of action, indications, and side effects of the major antiallergic and antiasthmatic drugs. When considering the ideal pharmacokinetic characteristics of a drug, a poorly metabolized drug may confer a lower variability in plasma concentrations and metabolism-based drug interactions, although poorly metabolized drugs may be prone to transporter-based disposition and interactions. The ideal pharmacological properties of a drug include high binding affinity, high selectivity, and appropriate association and dissociation rates. Finally, from a patient perspective, the frequency and route of administration are important considerations for ease of use.

Outpatient management of asthma in children age 5-11 years: guidelines for practice

PURPOSE

To increase awareness among nurse practitioners (NPs) regarding diagnostic and treatment guidelines for asthma for the 5-11 year age group recently updated by the National Asthma Education Prevention Program-Expert Panel 3 (NAEPP-EPR3).

DATA SOURCES

NAEPP-EPR3 guidelines for the diagnosis and management of asthma released from the National Heart, Lung, and Blood Institute in August 2007, selected clinical trials, meta-analyses, and clinical reviews.

CONCLUSIONS

Recent research has revealed that children suffering from asthma in the United States are underdiagnosed and their asthma is poorly controlled. Compelling evidence supports that children classified as having persistent asthma following NAEPP-EPR3 guidelines benefit from daily inhaled corticosteroid therapy, yet many are misclassified and undertreated.

IMPLICATIONS FOR PRACTICE

With application of current guidelines from NAEPP-EPR3, NPs can more effectively assess, diagnose, treat, and foster a collaborative self-management plan for children age 5-11 years. These interventions will result in an improved quality of life and decreased health risks for this young population.

Effect of long-term corticosteroid use on bone mineral density in children: a prospective longitudinal assessment in the childhood Asthma Management Program (CAMP) study

OBJECTIVE

Systemic corticosteroids are known to induce osteoporosis and increase the risk for fractures in adults and children. Inhaled corticosteroids have been shown to increase the risk for osteoporosis and fractures in adults at risk; however, long-term prospective studies of children to assess risks of multiple short courses of oral corticosteroids and chronic inhaled corticosteroids have not been performed. Thus, we assessed the effects of multiple short courses of oral corticosteroids and long-term inhaled corticosteroids on bone mineral accretion over a period of years.

METHODS

This was a cohort follow-up study for a median of 7 years of children who had mild-to-moderate asthma and initially were randomly assigned into the Childhood Asthma Management Program trial. Serial dual-energy radiograph absorptiometry scans of the lumbar spine for bone mineral density were performed for all patients. Annual bone mineral accretion was calculated for 531 boys and 346 girls who had asthma and were aged 5 to 12 years at baseline (84% of the initial cohort).

RESULTS

Oral corticosteroid bursts produced a dosage-dependent reduction in bone mineral accretion (0.052, 0.049, and 0.046 g/cm(2) per year) and an increase in risk for osteopenia (10%, 14%, and 21%) for 0, 1 to 4, and >or=5 courses, respectively, in boys but not girls. Cumulative inhaled corticosteroid use was associated with a small decrease in bone mineral accretion in boys but not girls but no increased risk for osteopenia.

CONCLUSIONS

Multiple oral corticosteroid bursts over a period of years can produce a dosage-dependent reduction in bone mineral accretion and increased risk for osteopenia in children with asthma. Inhaled corticosteroid use has the potential for reducing bone mineral accretion in male children progressing through puberty, but this risk is likely to be outweighed by the ability to reduce the amount of oral corticosteroids used in these children.

Clinical safety of inhaled corticosteroids for asthma in children: an update of long-term trials

Inhaled corticosteroids are established as the mainstay of maintenance therapy for chronic asthma. However, there remains some debate regarding the safety of long-term use of these agents, particularly in children. This concern mainly stems from the findings of short-term studies assessing the effects of inhaled corticosteroids on lower leg growth rate or the hypothalamic-pituitary-adrenal axis. However, the clinical relevance of these findings to long-term treatment is unknown and significant uncertainty exists regarding the predictive value of changes in cortisol levels and clinically relevant changes in growth or bone mineral density. To assess the safety of long-term use of inhaled corticosteroids in children with asthma, a systematic review of the literature was performed focusing on randomised, controlled studies of >or=12 months' duration, to obtain data with maximum relevance to clinical practice. Specific searches were conducted to identify studies examining each of the following three areas: growth, bone mineral density and cortisol levels. Fourteen studies met the inclusion criteria for statural growth, four for bone mineral density, and ten for cortisol levels. There was some evidence of a small decrease in statural growth during the initial period of inhaled corticosteroid therapy. This effect was more marked at daily doses of >200 microg and did not apply to all treatment regimens. Studies examining final attained adult height found no difference between patients treated with inhaled corticosteroids and those receiving nonsteroidal therapy. None of the studies investigating effects on bone mineral density found any adverse effects of inhaled corticosteroid therapy. Finally, recommended doses of inhaled corticosteroids generally had little or no effect on plasma- or urinary-cortisol levels versus nonsteroidal therapy. In conclusion, this literature review supports the theory that recommended doses of inhaled corticosteroids can be administered to children for the long-term management of asthma with minimal risk of clinically relevant adverse effects on growth, bone density or cortisol levels.

Considerations in the long-term management of asthma in ambulatory patients

PURPOSE

The goals of treatment and drug therapies used for long-term asthma control, classification of the disease by severity, and treatment based on severity are reviewed, with an emphasis on recent controversies in treatment approach and safety concerns.

SUMMARY

Patient education and written asthma self-management and action plans are essential components of asthma treatment because of the need for patients to acquire substantial knowledge and skills in self-care. Inhaled corticosteroids are the most effective long-term-control therapy and usually suffice as monotherapy for mild persistent asthma. Adding a long-acting, inhaled beta2 agonist to the inhaled corticosteroid is preferred for moderate and severe persistent disease despite safety concerns. Omalizumab use is limited to selected patients with moderate-to-severe allergic asthma and an inadequate response to inhaled corticosteroids.

CONCLUSION

The long-term control of asthma requires substantial patient knowledge and skill. Persistent disease is best managed by inhaled corticosteroids and if it is moderate or severe, long-acting, inhaled beta2 agonists in combination with inhaled corticosteroids.

Linear growth in prepubertal asthmatic children treated with montelukast, beclomethasone, or placebo: a 56-week randomized double-blind study

BACKGROUND

Antileukotrienes and inhaled corticosteroids are asthma controller agents widely used in the treatment of pediatric asthma.

OBJECTIVE

To evaluate the effects of montelukast and beclomethasone on linear growth in prepubertal asthmatic children for 1 year.

METHODS

This was a 30-center study of boys (6.4-9.4 years old) and girls (6.4-8.4 years old) at Tanner stage I with mild, persistent asthma. After a placebo run-in period, 360 patients were randomized in equal ratios to double-blind, double-dummy treatment with 5 mg of montelukast, 200 microg of beclomethasone twice daily (positive control), or placebo for 56 weeks; 90% of the patients completed the study. The primary end point was linear growth velocity, measured using a stadiometer.

RESULTS

Linear growth rates were similar between the montelukast and placebo groups; the mean difference for the year was 0.03 cm. The mean growth rate with beclomethasone was significantly less than with placebo (-0.78 cm) or montelukast (0.81 cm) (P < .001 for both). Median percentage of days with beta-agonist use was greater with placebo (14.58%) vs montelukast (10.55%) or beclomethasone (6.65%) (P < .05 for all). More patients used oral corticosteroid rescue with placebo (34.7%) than with montelukast (25.0%) or beclomethasone (23.5%). An imbalance in bone marker levels was seen with beclomethasone but not with montelukast.

CONCLUSION

In prepubertal asthmatic children, montelukast did not affect linear growth, whereas the growth rate with beclomethasone was significantly decreased during 1 year of treatment.

Pharmacologic characteristics and adrenal suppression with newer inhaled corticosteroids: A comparison of ciclesonide and fluticasone propionate

BACKGROUND

Inhaled corticosteroids (ICSs) are the most potent anti-inflammatory choice for patients with asthma. Selecting the most appropriate ICS for a patient requires a thorough understanding of the pharmacologic properties of each drug.

OBJECTIVE

This review details the pharmacologic properties of ciclesonide (CIC) and fluticasone propionate (FP) and reviews the available data on suppression of the hypothalamic-pituitary-adrenal axis as a measure of systemic exposure and safety profile.

METHODS

Clinical studies and case reports were identified through a MEDLINE and EMBASE search of English-language articles. The databases were searched for the years 1990 to April 2005 using the terms ciclesonide, fluticasone, ICS, and adrenal suppression. All studies were clinical trials of pharmacologic properties of the ICSs in humans.

RESULTS

A total of 1082 articles were identified. CIC and FP are 2 of the most potent ICSs. Both have high receptor-binding affinities (12 times and 18 times that of dexamethasone, respectively), and both may provide enhanced respiratory effects through a prolonged pulmonary residence time. The CIC metered dose inhaler dispenses smaller and more highly respirable particles than FP (1.1-2.1 pm vs 2.8-3.2 microm, respectively). Therefore, a greater percentage of administered CIC is topically deposited in the lungs (52% vs 12% to 13% for FP). CIC is delivered as an inactive parent compound, which is converted to its active metabolite, desisobutyryl-CIC (des-CIC), by esterases in the airways. More than 50% of a dose of CIC is deposited and distributed evenly throughout the lungs of healthy adults; lipid conjugation in the lung also may increase lung residence time. On entering the systemic circulation, both corticosteroids are rapidly cleared by the liver (elimination half-life of 3.5 hours for CIC vs 7.8 hours for FP). However, plasma protein binding is greater with CIC/des-CIC (99%/ approximately 99%) than FP (90%), resulting in reduced amounts of des-CIC (<I%) versus FP (10%) circulating free in the plasma. Although studies of low or medium doses of FP have produced conflicting results, high doses of FP (>660 pg/d) may result in adrenal suppression. CIC has not been reported to produce any significant adrenal suppression throughout its studied dose range (up to 1280 micro/d).

CONCLUSIONS

A review of the literature suggests that CIC, as compared with FP, achieves greater pulmonary deposition, causes fewer adverse oropharyngeal effects, deposits less biologically active drug in the systemic circulation, and has less potential for adrenal suppression.

Effects of inhaled steroids on growth, bone metabolism, and adrenal function

For children who have persistent asthma of any degree, ICS treatment is recommended. Although topical airway corticosteroid therapy has improved the control of asthma markedly while lessening the risk of corticosteroid side effects, the use of ICS continues to be accompanied by a fear of potential adverse systemic effects. Unfortunately, these fears result in some children being deprived of appropriate and effective treatment or even exposed to a greater risk of periodic oral corticosteroid treatment. Nevertheless, because these agents may be used for long periods of time in a large number of children, safety issues are paramount. Important overall conclusions seem well supported by the literature. First, ICS used in small doses present no significant risk for systemic side effects. When ICS are used at higher dosages and continuously for long periods of time, important differences in drug characteristics, in particular the efficiency of inactivation of swallowed drug (which does not exert a therapeutic effect prior to gaining access to the systemic circulation), affect the ratio of therapeutic to systemic effect of individual ICS. From a practical viewpoint, the long-term clinical history of ICS therapy is informative. Clinically significant suppression of the HPA axis resulting from ICS therapy alone is rare. Detectable suppression of childhood growth can occur when ICS with relatively poor first-pass inactivation are administered at doses greater than or equal to 400 microg per day; this effect on 1-year growth is reduced when clinically equivalent doses of ICS with improved first-pass inactivation of swallowed drug are used. Administration of ICS alone, however, is not associated with any detectable effects on final adult height. Harmful effects of ICS on bone metabolism, although not yet studied adequately, are not expected with the use of an ICS dosage that does not suppress basal HPA axis function or childhood growth. An important caveat to these conclusions is that they refer to the use of ICS used alone and in recommended doses, not in combination with intranasal or other topical corticosteroids. Differences in safety profiles among the available ICS exist, but there are few direct comparative studies attempting to establish rank in benefit-to-risk ratios. The safety profile of all ICS preparations, which focus anti-inflammatory effects on the lung, is markedly better than that of oral glucocorticoids. Risk of adverse effects is minimized by using the lowest effective dosage, by limiting systemic availability of the drug through careful selection of the inhalation device and proper technique, by the adjunct use of alternative anti-inflammatory agents, and, when higher doses are required, by choice of ICS medication. Monitoring growth in children is a sensitive method of detecting significant ICS systemic effects and can enhance a family's confidence in the safety of the medication. When long-term, high-dose therapy is required, periodic evaluations of adrenal function and bone density may be advisable. ICS are highly effective and, because their benefits clearly exceed potential risks, can be used safely in children who have persistent asthma.

Inhaled steroids for children: effects on growth, bone, and adrenal function

Inhaled corticosteroids are the first-line therapy for persistent asthma in children. Major safety concerns of long-term inhaled corticosteroid therapy include suppression of adrenal function and impaired growth and bone development. Proper interpretation of inhaled corticosteroid safety requires knowledge of differences among various drug devices. Dosage, type of inhaler device used, patient technique, and characteristics of the individual drug influence systemic effects of inhaled corticosteroids. Systemic side effects can occur when continuous high-dose treatment is required for severe asthma or when prescribed dosage is excessive and compliance is unusually good. Recent studies confirm that benefits of inhaled corticosteroids outweigh potential adverse effects and the risks associated with poorly controlled asthma.

[Adverse events of inhaled steroids in childhood]

The adverse events of the inhaled steroids on growth and bone mineralization concern the pediatricians. From the available current data, we exposed the following conclusions: 1) Inhaled steroids must be preferred to oral steroids; 2) Short, middle and long-term adverse effects of inhaled steroids have to be differentiated. Only the long-term effects reflect possible sequela; 3) The adverse effects are specific from the considered inhaled steroids, the most recent available drugs having less adverse effects on bone and growth; 4) Recent data did not show consequences on the adult height and bone mineralization; 5) Recommendations in the use of inhaled steroids must be known by the practitioners in order to limit the adverse events of these drugs. Growth need to be surveyed in children with inhaled steroids and more studies are still necessary. In addition, we enhanced that local adverse effects should be sought by the physicians. Cough after inhalation was frequent and might be a negative factor of compliance.

Systemic effects of inhaled corticosteroids in children

PURPOSE OF REVIEW

Inhaled corticosteroids (ICS) are first-line therapy for persistent asthma in children. Major safety concerns about long-term ICS therapy include suppression of adrenal function, growth, and bone development. Proper interpretation of ICS safety studies requires knowledge of differences between various ICS drug/delivery device systems.

RECENT FINDINGS

Dosage, type of inhaler device used, patient technique, and characteristics of the individual drug influence systemic effects of ICS. Reports of adrenal insufficiency occur but are rare and are confined to children receiving high doses of ICS. Dose-related inhibition of growth is detectable as ICS dosage increases, but appears temporary, more pronounced in childhood, and is not associated with reduction in final height. Moderate-dose ICS therapy is not associated with significant changes in measurements of bone density, but more studies of high doses and of therapy in adolescents are needed.

SUMMARY

Recent studies confirm that benefits of ICS, properly prescribed and used, clearly outweigh not only their potential adverse effects but also the risks associated with poorly controlled asthma.