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Smith T, Mills K, Cober MP, Fenn NE, Hill C, King M, Pauley JL, Eiland L, Sierra C, Omecene NE. Updates in the treatment of asthma in pediatrics: A review for pharmacists. Am J Health Syst Pharm 2024; 81:e210-e219. [PMID: 38146826 DOI: 10.1093/ajhp/zxad326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Indexed: 12/27/2023] Open
Abstract
PURPOSE The purpose of this review is to summarize the management of asthma in children and to highlight different guideline-based approaches. This review also discusses literature regarding the use of corticosteroids, both inhaled and systemic, as well as biologic agents, in asthma management. SUMMARY Asthma is a common chronic respiratory condition in the pediatric population and has evolved into a highly patient-specific disease. Of the 2 main asthma guidelines, one developed by the National Asthma Education and Prevention Program was recently published as a focused update in 2020. The other, from the Global Initiative for Asthma, focuses on a global strategy for management and prevention, with the most recent update in 2023. Both reports discuss diagnosis, assessment, and treatment of asthma in adults and children. Treatment is designed as a stepwise approach in both reports, although there are key differences. This article focuses on gaps in these guidelines, including the use of bronchodilators and inhaled corticosteroids with single maintenance and reliever therapy and long-acting muscarinic antagonists in children. It also reviews treatment in children under 5 years of age, although recommendations are limited due to a lack of evidence in this age group. Finally, this review discusses considerations for emerging treatments, including biologics, for patients who are difficult to treat. CONCLUSION New treatment strategies and agents have emerged in the treatment of pediatric asthma. Pharmacists play a key role in providing education about, dispensing, and recommending the newest evidence-based treatment options for children.
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Affiliation(s)
- Tara Smith
- HCA Florida West Healthcare, Pensacola, FL, USA
| | | | - M Petrea Cober
- Akron Children's Hospital, Akron, OH, and College of Pharmacy, Northeast Ohio Medical University, Rosstown, OH, USA
| | - Norman E Fenn
- Manchester University College of Pharmacy, Natural, and Health Sciences, Fort Wayne, IN
- Parkview Women's and Children's Hospital, Fort Wayne, IN, USA
| | - Carolyn Hill
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Morgan King
- Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
| | | | - Lea Eiland
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Caroline Sierra
- Loma Linda University School of Pharmacy, Lorna Linda, CA, USA
| | - Nicole E Omecene
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
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Lee H. Vitamin E acetate as linactant in the pathophysiology of EVALI. Med Hypotheses 2020; 144:110182. [PMID: 33254504 PMCID: PMC7422838 DOI: 10.1016/j.mehy.2020.110182] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/25/2020] [Accepted: 08/11/2020] [Indexed: 11/11/2022]
Abstract
The recent identification of Vitamin E acetate as one of the causal agents for the e-cigarette, or vaping, product use associated lung injury (EVALI) is a major milestone. In membrane biophysics, Vitamin E is a linactant and a potent modulator of lateral phase separation that effectively reduces the line tension at the two-dimensional phase boundaries and thereby exponentially increases the surface viscosity of the pulmonary surfactant. Disrupted dynamics of respiratory compression-expansion cycling may result in an extensive hypoxemia, leading to an acute respiratory distress entailing the formation of intraalveolar lipid-laden macrophages. Supplementation of pulmonary surfactants which retain moderate level of cholesterol and controlled hypothermia for patients are recommended when the hypothesis that the line-active property of the vitamin derivative drives the pathogenesis of EVALI holds.
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Affiliation(s)
- Hanjun Lee
- Department of Biology, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, United States.
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Pincheira MA, Bacharier LB, Castro-Rodriguez JA. Efficacy of Macrolides on Acute Asthma or Wheezing Exacerbations in Children with Recurrent Wheezing: A Systematic Review and Meta-analysis. Paediatr Drugs 2020; 22:217-228. [PMID: 31939108 DOI: 10.1007/s40272-019-00371-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The role of macrolides for treatment of children with acute asthma or wheezing exacerbations is unclear. OBJECTIVE The aim of this systematic review was to evaluate the effectiveness of macrolides in children with recurrent wheezing presenting with acute asthma or wheezing exacerbation. METHODS We conducted an electronic search in MEDLINE, EMBASE, CINAHL, LILACS, CENTRAL, and ClinicalTrials.gov. STUDY SELECTION CRITERIA Randomized controlled trials of macrolides (any macrolide) compared with placebo or standard treatment in children up to 18 years with recurrent wheezing/asthma presenting with an acute exacerbation. OUTCOMES Primary outcomes were need for hospitalization and/or time of acute asthma/wheezing symptoms resolution; secondary outcomes were duration of stay in the emergency department (ED)/clinic, severity of symptoms of the index episode, use of additional systemic corticosteroids or short active β-2 agonists, changes in lung function measures, ED visit/hospitalization during first week after index episode, time to next exacerbation, or adverse effects (AEs). RESULTS Only three studies met the inclusion criteria (n = 334 children, 410 treated episodes); two studies included recurrent wheezers and the third included asthmatic children. There was no difference in hospitalization between groups, but children treated with macrolides had a significantly lower time to symptoms resolution than controls, although the magnitude of benefit remains to be quantified due to no normal distribution data presented. There was no difference in time to next episode of exacerbation (HR 0.96; 95% CI 0.71-1.28; I2 = 0%; p = 0.77). In one study, children receiving macrolides had a significant decrease in the severity of symptoms, decrease use of salbutamol, and another study showed improved lung function. No study evaluated antibiotic resistance development. CONCLUSIONS Limited evidence support that a macrolide trial could be considered in children with acute asthma or recurrent wheezing exacerbation.
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Affiliation(s)
- Mauricio A Pincheira
- Division of Pediatrics, Department of Pediatric Pulmonology and Cardiology, School of Medicine, Pontificia Universidad Católica de Chile, Lira 44, 1er Piso, casilla 114-D, Santiago, Chile
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO, USA
| | - Jose A Castro-Rodriguez
- Division of Pediatrics, Department of Pediatric Pulmonology and Cardiology, School of Medicine, Pontificia Universidad Católica de Chile, Lira 44, 1er Piso, casilla 114-D, Santiago, Chile.
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Michelet D, Julien-Marsollier F, Bahaji M, Dahmani S. Potential beneficial effect of pre-operative nebulisation of corticosteroids in children with upper respiratory tract infection. Eur J Anaesthesiol 2019; 36:796-797. [PMID: 31483344 DOI: 10.1097/eja.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Daphné Michelet
- From the Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris Sorbonne Cité (DM, FJ-M, MB, SD), Paris Diderot University (Paris VII), PRES Paris Sorbonne Cité (DM, FJ-M, MB, SD) and DHU PROTECT, Inserm U1141, Robert Debré University Hospital, Paris, France (DM, FJ-M, SD)
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Price DB, Gefen E, Gopalan G, Miglio C, McDonald R, Thomas V, Wan Yau Ming S. Real-life effectiveness and safety of the inhalation suspension budesonide comparator vs the originator product for the treatment of patients with asthma: a historical cohort study using a US health claims database. Pragmat Obs Res 2017; 8:69-83. [PMID: 28572742 PMCID: PMC5441674 DOI: 10.2147/por.s132839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objective The objective of this study was to determine whether the effectiveness of budesonide comparator is non-inferior to budesonide reference in the prevention of asthma exacerbations. Asthma-related hospitalizations and safety were also examined. Methods This study used a matched, historic cohort design. Data were drawn from the Clinformatics™ Data Mart US claims database and included a 1-year baseline, starting 1 year before the index prescription date, and a 1-year outcome period. Patients received budesonide comparator or reference treatment. The primary outcome was the rate of asthma exacerbations. Non-inferiority for budesonide comparator vs budesonide reference was established if the 95% confidence interval (CI) upper limit of mean difference in proportions between treatments was <15%. Secondary outcomes examined rate of asthma-related hospitalizations and adverse events (AEs). Results The budesonide comparator and reference-matched cohorts each included 3109 patients. The adjusted upper 95% CI for the difference in proportions of patients experiencing asthma exacerbations was 0.035 (3.5%), demonstrating non-inferiority. Cohorts did not significantly differ in the rate of asthma exacerbations (adjusted rate ratio [RR]=1.04, 95% CI: 0.95–1.14) or rate of asthma-related hospitalizations (adjusted RR=1.10, 95% CI: 0.99–1.24) after adjusting for baseline confounders. No asthma exacerbations occurred during the outcome period in 72.9% of budesonide comparator patients and 71.8% of budesonide reference patients. No asthma-related hospitalizations occurred in 77.9% of patients in the budesonide comparator cohort and 79.0% of patients in the budesonide reference cohort. The most frequent AEs were throat irritation (≤0.4% of patients) and hoarseness/dysphonia (0.02% of patients). AEs did not significantly differ between treatment cohorts. Conclusion In this real-life study, non-inferiority of the budesonide comparator vs reference was met for the primary end point of asthma exacerbation rates. Asthma-related hospitalization and AE rates did not differ between the two treatment cohorts. The budesonide comparator is an effective and safe treatment alternative for asthma exacerbations.
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Affiliation(s)
- David B Price
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Eran Gefen
- Teva Pharmaceuticals, Petach Tikva, Israel
| | | | - Cristiana Miglio
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Rosie McDonald
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Vicky Thomas
- Observational and Pragmatic Research Institute, Singapore, Singapore
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Raissy HH, Blake K. As Needed Use of Inhaled Corticosteroids for Management of Mild Persistent Asthma in Children. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2011; 24:231-233. [PMID: 22375279 PMCID: PMC3281291 DOI: 10.1089/ped.2011.0123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 10/03/2011] [Indexed: 11/12/2022]
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Self TH, Chrisman CR, Jacobs AR, Vo NH, Winton JC. Preventing emergency department visits and hospitalizations for asthma by use of oral corticosteroids at home: are we adhering to national guidelines? J Asthma 2010; 47:1123-7. [PMID: 21039210 DOI: 10.3109/02770903.2010.514641] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Oral corticosteroids (OCS) in the home management of asthma exacerbations have been recommended in the NIH/NHLBI guidelines since 1991. As a routine component of written action plans, OCS treatment at home is associated with reduced emergency department (ED) visits and hospitalizations as well as decreased mortality. METHODS A literature search of English language journals from 1991 to 2009 was performed using several databases, including PubMed, EMBASE, and SCOPUS. We assessed studies that evaluated adherence to national guidelines for home management of asthma exacerbations. RESULTS Our review of the literature found that several studies reveal that a small percentage (<3-26%) of patients are receiving OCS at home to manage asthma exacerbations prior to an ED visit. Additional studies were found showing very low use of written action plans, strongly suggesting lack of OCS for home management of asthma exacerbations. CONCLUSIONS Despite evidence of reduced ED visits and hospitalizations and the recommendations of national and international guidelines, the home use of OCS in managing asthma exacerbations remains unacceptably low. New strategies are needed to ensure home use of OCS as part of written action plans to prevent ED visits and hospitalizations for asthma exacerbations.
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Affiliation(s)
- Timothy H Self
- College of Pharmacy, University of Tennessee Health Science Center and Methodist University Hospital, Memphis, TN 38163, USA.
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Abstract
The management of acute asthma exacerbations in children remains controversial and the latest guidelines (Expert Panel Report [EPR]-3 2007 and the Global Initiative of Asthma 2008) leave several questions unanswered. This review summarizes the most up-to-date information on the practical prevention and control of asthma attacks in children, and describes the 20-year experience of a major tertiary asthma clinic with the administration of inhaled corticosteroids in this setting. The following subjects are discussed: the knowledge and skills required by the parents regarding asthma and its treatment, how to prevent or minimize exacerbations in asthmatic children, the drugs used in the treatment of exacerbations and their order of administration, and the steps to follow after discharge from the emergency department or after a severe asthma exacerbation. The efficacy of inhaled corticosteroids in the management of acute asthma exacerbations in children, both at home and in the emergency department, is discussed in detail. The goal of asthma-management programs is to arm parents with the skills and knowledge to prevent, detect and successfully control most exacerbations of asthma in children at home.
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Affiliation(s)
- Benjamin Volovitz
- Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Volovitz B. Inhaled corticosteroids as rescue medication in asthma exacerbations in children. Expert Rev Clin Immunol 2010; 4:695-702. [PMID: 20477119 DOI: 10.1586/1744666x.4.6.695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The role of inhaled corticosteroids (ICS) as rescue medication for asthma exacerbations in children is controversial. ICS have the important potential advantage of direct delivery to the airways, which substantially reduces the risk of the adverse systemic effects that may be associated with oral corticosteroids. Oral corticosteroids are still preferred for severe attacks. Five randomized, controlled studies performed at home and six performed in the emergency department indicated that ICS are at least as effective as the oral route. Our pediatric out-patient asthma clinic has been using ICS for asthma exacerbations for more than 25 years. The key elements to success are the administration of repetitive doses at least four-times higher than the maintenance dose and parental adherence to the treatment plan. This article reviews the findings in the literature favoring this approach and describes our methodology in detail.
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Affiliation(s)
- Benjamin Volovitz
- Asthma Research and Education, Pediatric Asthma Clinic and Research Laboratories, Schneider Children's Medical Center of Israel, 14 Kaplan Street, Petah Tiqwa 49202, Israel.
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Current world literature. Curr Opin Pulm Med 2010; 16:77-82. [PMID: 19996898 DOI: 10.1097/mcp.0b013e328334fe23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ehtezazi T, Saleem I, Shrubb I, Allanson DR, Jenkinson ID, O’Callaghan C. The Interaction Between the Oropharyngeal Geometry and Aerosols via Pressurised Metered Dose Inhalers. Pharm Res 2009; 27:175-86. [DOI: 10.1007/s11095-009-9994-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 10/05/2009] [Indexed: 11/30/2022]
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Øymar K, Halvorsen T. Emergency presentation and management of acute severe asthma in children. Scand J Trauma Resusc Emerg Med 2009; 17:40. [PMID: 19732437 PMCID: PMC2749010 DOI: 10.1186/1757-7241-17-40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 09/04/2009] [Indexed: 01/19/2023] Open
Abstract
Acute severe asthma is one of the most common medical emergency situations in childhood, and physicians caring for acutely ill children are regularly faced with this condition. In this article we present a summary of the pathophysiology as well as guidelines for the treatment of acute severe asthma in children. The cornerstones of the management of acute asthma in children are rapid administration of oxygen, inhalations with bronchodilators and systemic corticosteroids. Inhaled bronchodilators may include selective b2-agonists, adrenaline and anticholinergics. Additional treatment in selected cases may involve intravenous administration of theophylline, b2-agonists and magnesium sulphate. Both non-invasive and invasive ventilation may be options when medical treatment fails to prevent respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances.
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Affiliation(s)
- Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Paediatrics, Haukeland University Hospital, Bergen, Norway
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