Which factors predict success after discontinuation of inhaled budesonide therapy in children with asthma?

Loss of asthma control in inner city children with asthma after withdraw of asthma controller medication

To determine what percentage of inner-city children with asthma would lose asthma control when taken off asthma controllers, a retrospective analysis was performed on inner-city asthmatic children who achieved asthma control in an asthma specific disease management program. Once disease control was achieved patients had stepwise reduction of asthma controllers based on the National Asthma Education and Prevention Program (NAEPP) Expert Review Panel (EPR) 2 guidelines. In patients who were taken off all controllers, probability of maintaining asthma control at the first visit after cessation of these medications was significantly lower compared to patients kept on inhaled corticosteroids. We conclude that cessation of asthma controllers in previously well controlled inner-city asthmatic children results in loss of asthma control in a significant number of these patients. Data support recommendations from national asthma guidelines to step down controller therapy, but clinical monitoring is important to reduce impairment due to loss of control.

Prognosis of adult asthma after normalization of bronchial hyperresponsiveness by inhaled corticosteroid therapy

BACKGROUND

Inhaled corticosteroids (ICSs) are the most effective anti-inflammatory drugs for adult asthma and can improve not only clinical symptoms but also bronchial hyperresponsiveness (BHR). However, the prognosis of adult asthma has not been well studied, and it remains to be elucidated precisely how long treatment with ICSs should be continued once clinical remission is achieved.

OBJECTIVES

We examined whether ICS use could be withdrawn or reduced without exacerbation of disease.

METHODS

We retrospectively studied 374 adult patients with asthma to determine which factors predicted the elimination or reduction of ICS treatment without exacerbations of disease after the achievement of normalized BHR to acetylcholine. The patients were classified into three groups: Group 1 had symptoms within 6 months of normalization and needed to continue therapy; group 2 received the equivalent of >or= 400 microg fluticasone propionate until BHR normalization, did not have symptoms in the 6 months after normalization, and then had their doses of ICSs halved; and group 3 received the equivalent of <or= 200 microg fluticasone propionate at an enrollment, did not have symptoms in the 6 months after normalization, and then had all ICSs withdrawn. The primary outcome measure was the presence of clinical symptoms. We used multiple logistic regression and a Kaplan-Meier analysis to analyze the factors predicting remission.

RESULTS

Twenty-nine patients in group 3 remained asymptomatic for more than 30 months (mean 47.1 +/- 12.4 months) after discontinuing ICS therapy. The predictive markers of remission were low levels of eosinophils in the sputum, high %V(50) at the first hospital visit, and the need for only a low daily dose of ICS to induce normalized BHR. Conversely, patients with severe BHR at the first hospital visit, low %FEV(1) at normalized BHR, and a need for high-dose ICSs to reach normalized BHR could not reduce or discontinue treatments.

CONCLUSION

Some adult patients with asthma whose BHR is normalized by ICS therapy can achieve remission from disease exacerbation after discontinuation of ICSs. However, patients with severe asthma or asthma of long duration may not achieve remission even if their BHR is normalized.

Effectiveness of budesonide nebulising suspension compared to disodium cromoglycate in early childhood asthma

OBJECTIVE

The optimal treatment for early childhood asthma remains controversial. Budesonide (BUD) has shown superiority over placebo in infants, and over disodium cromoglycate (DSCG) in children aged > 2 years. The aim of this double-blind, randomised, parallel-group study was to compare the effectiveness of nebulised BUD and DSCG in asthmatic children aged < 36 months.

RESEARCH DESIGN AND METHODS

82 infants (mean age 18.0 months [range, 11.6-31.2 months]) with suspected asthma (three exacerbations of dyspnoea and wheezing during the past 12 months, with one or more exacerbations in the past 3 months) were treated for 3 months with nebulised BUD (Pulmicort Respules) 0.5 mg/2 mL bid or DSCG 20 mg/2 mL tid. Follow-up was at 6 months.

MAIN OUTCOME MEASURES AND RESULTS

Patients treated with BUD had a lower exacerbation rate than DSCG-treated patients after 3 months of treatment (5.4% vs. 31.7%; p = 0.003) and towards the end of follow-up (30% vs. 49%; p = 0.062). During treatment, days without cough were 80% and 65% for BUD and DSCG, respectively (p = 0.014), and nights without cough were 89% and 78%, respectively (p = 0.016). Side-effects were mild and of similar frequency in both groups.

CONCLUSIONS

Inhaled nebulised BUD was well tolerated and more effective than nebulised DSCG in reducing the incidence of asthma exacerbations and days with symptoms. These beneficial effects of BUD were maintained throughout the 6-month follow-up.

Risk factors associated with occurrence of clinical deterioration after cessation of beclomethasone in asthmatic children and adolescents

Despite recent advances in the treatment of asthma using inhaled corticosteroids, the outcome for children after its discontinuation is not well known. This study aims to analyze the rate of clinical deterioration and related risk factors after beclomethasone withdrawal in asthmatic children and adolescents. One hundred two subjects with moderate or severe persistent asthma, who had started treatment with beclomethasone at the age of 2-11 years, were followed for 1 year after drug cessation. Depending on the occurrence of clinical deterioration, they were allocated to two groups, and then comparisons were made with respect to clinical criteria and skin prick test results. Statistical analysis was undertaken by using descriptive statistics and Cox's regression model. Treatment with beclomethasone had to be restarted in 28 patients (27.5%) because of relapse. There was a significant association with the risk of clinical deterioration with mother's history of asthma [hazard ratio (HR) = 2.19, 95% CI = 1.01-4.76, p = 0.04] and father's history of asthma and/or allergic rhinitis (HR = 2.34, 95% CI = 1.06-5.26, p = 0.03). A period shorter than 6 months without symptoms before prophylaxis cessation (HR = 2.26, 95% CI = 0.98-5.26, p = 0.05) and atopy (RH = 2.75, 95% CI = 0.94-7.69, p = 0.06) were also associated with risk of relapse but with marginal statistical significance. Results suggest that clinical benefits were maintained for at least 1 year in the majority of the children after the cessation of prophylaxis. Special attention must be given to those with atopy and a parental history of asthma and rhinitis because of the risk of clinical deterioration.

Successful withdrawal of inhaled corticosteroids in childhood asthma

OBJECTIVE

Although inhaled corticosteroids are useful and effective in the prophylaxis of childhood asthma, there is a dearth of information regarding the duration of treatment. The present study was undertaken to assess the possibility of successful withdrawal of inhaled corticosteroids in childhood asthma following good control of the disease.

METHODOLOGY

The study was carried out at the Asiri Hospital, Colombo, Sri Lanka and was a prospective observational clinical study. The participants were consecutive children with documented moderately severe and severe asthma seen over a period of 4 years from January 1990 and followed up to December 2003. Patients were allocated randomly to receive either beclomethasone dipropionate or budesonide. Initial dose of the selected drug was 300, 400 or 600 microg/day, depending on the child's age. After a period of stabilization, the dose was reduced from the starting dose to a maintenance level of 200, 300 or 400 microg/day, respectively. Once sustained control had been maintained for a period ranging from 9 to 18 months, gradual withdrawal was attempted. The dosage was reduced by 50-100 microg each time, at intervals of 3 months. Long-term follow up was maintained following withdrawal of inhaled corticosteroids. Breakthrough wheezing, acute severe attacks, hospitalization for wheezing and absence from school were used to assess the response.

RESULTS

Eighty-six children were recruited into the study. Eighty children responded well. The initial period on a high dose of corticosteroid was 8.4 months (range 4-12 months) and the average period of maintenance dosing was 11.7 months (range 9-18 months). The average time taken for withdrawal was 12.6 months (range 9-18 months). Successful withdrawal was achieved in 73 children. In this group, the mean total duration of treatment was 27.4 months (range 20-44 months). Up to December 2003, the subjects had been observed for an average period of 97.1 months (range 86-121 months) following withdrawal of inhaled corticosteroids. Of the 73 children in whom corticosteroids were withdrawn, 57 (78%) have remained well without any episodes of wheezing, and 14 (19%) have had mild episodes of wheezing that were easily controlled by bronchodilators. No patient needed hospitalization, long-term treatment or systemic corticosteroids. In two (3%) patients, it was necessary to restart inhaled corticosteroids because of troublesome recurrences.

CONCLUSION

It is possible to gradually withdraw inhaled corticosteroids in a significant proportion of asthmatic children once good control has been sustained on a maintenance dose for a considerable period.