Glucocorticoids and growth in asthmatic children

Low-dose glucocorticoids withdrawn in systemic lupus erythematosus: a desirable and attainable goal

OBJECTIVES

To assess the risk of flare in systemic lupus erythematosus (SLE) patients after low-dose glucocorticoid (GC) discontinuation and to evaluate the risk factors of flare.

METHODS

SLE patients who ever discontinued GCs were identified from the Peking University First Hospital SLE cohort. The disease flare profile after GC discontinuation was analysed. The flare rate was analysed using Kaplan-Meier analysis. Cox regression was used to determine the effects of variables on SLE flare. A prognostic nomogram using Cox proportional hazards regression modelling was developed.

RESULTS

A total of 132 SLE patients were eligible for the final analysis. They were followed up for a median of 21.8 months (interquartile range 9.01-36.7). The cumulative probability of flare after GC discontinuation was 8.3% at 6 months, 16.8% at 1 years and 27.5% at 2 years. In multivariate Cox analysis, hypocomplementemia and serologically active clinically quiescent (SACQ) were independent risk factors of flare [hazard ratio (HR0 2.53 (95% CI 1.32, 4.88); HR 3.17 (95% CI 1.44, 6.97), respectively]. Age ≥40 years at GC withdrawal and hydroxychloroquine (HCQ) usage were independent protective factors of flare [HR 0.53 (95% CI 0.29, 0.99); HR 0.32 (95% CI 0.17, 0.62), respectively]. The protective effect of HCQ was dosage related. From the perspective of different tapering strategies embodied as the duration from prednisone 5 mg/day to complete discontinuation, a slower tapering strategy (12-24 months) significantly reduced the risk of flare compared with a faster tapering strategy (<3 months) [HR 0.30 (95% CI 0.11, 0.82), P = 0.019]. The prognostic nomogram including the aforementioned factors effectively predicted the 1 and 2 year probability of being flare-free.

CONCLUSION

Low-dose GC is feasibly discontinued in real-life settings. SACQ and younger age are potential risk factors of SLE flare, while HCQ use and slow GC tapering to withdrawal can reduce relapse. The visualized model we developed may help to predict the risk of flare among SLE patients who discontinued GC.

How can we minimise the use of regular oral corticosteroids in asthma?

Options to achieve oral corticosteroid (OCS)-sparing have been triggering increasing interest since the 1970s because of the side-effects of OCSs, and this has now become achievable with biologics. The Société de Pneumologie de Langue Française workshop on OCSs aimed to conduct a comprehensive review of the basics for OCS use in asthma and issue key research questions. Pharmacology and definition of regular use were reviewed by the first working group (WG1). WG2 examined whether regular OCS use is associated with T2 endotype. WG3 reported on the specificities of the paediatric area. Key “research statement proposals” were suggested by WG4. It was found that the benefits of regular OCS use in asthma outside episodes of exacerbations are poorly supported by the existing evidence. However, complete OCS elimination couldn’t be achieved in any available studies for all patients and the panel felt that it was too early to conclude that regular OCS use could be declared criminal. Repeated or prolonged need for OCS beyond 1 g·year⁻¹ should indicate the need for referral to secondary/tertiary care. A strategic sequential plan aiming at reducing overall exposure to OCS in severe asthma was then held as a conclusion of the workshop.

A yearly cumulative OCS dose above 1 g should be considered unacceptable in severe asthma and should make the case for referralhttp://bit.ly/34GAYLX

Pediatric asthma: An unmet need for more effective, focused treatments

BACKGROUND

Despite remarkable advances in our understanding of asthma, there are still several unmet needs associated with the management of pediatric asthma.

METHODS

A two-day, face-to-face meeting was held in London, United Kingdom, on October 28 and 29, 2017, involving a group of international expert clinicians and scientists in asthma management to discuss the challenges and unmet needs that remain to be addressed in pediatric asthma.

RESULTS

These unmet needs include a lack of clinical efficacy and safety evidence, and limited availability of non-steroid-based alternative therapies in patients <6 years of age. An increased focus on children is needed in the context of clinical practice guidelines for asthma; current pediatric practice relies mostly on extrapolations from adult recommendations. Furthermore, no uniform definition of pediatric asthma exists, which hampers timely and robust diagnosis of the condition in affected patients.

CONCLUSIONS

There is a need for a uniform definition of pediatric asthma, clearly distinguishable from adult asthma. Furthermore, guidelines which provide specific treatment recommendations for the management of pediatric asthma are also needed. Clinical trials and real-world evidence studies assessing anti-immunoglobulin E (IgE) therapies and other monoclonal antibodies in children <6 years of age with asthma may provide further information regarding the most appropriate treatment options in these vulnerable patients. Early intervention with anti-IgE and non-steroid-based alternative therapies may delay disease progression, leading to improved clinical outcomes.

Inhaled corticosteroid related adrenal suppression detected by poor growth and reversed with ciclesonide

INTRODUCTION

This case series intends to highlight the association between decreased linear growth velocity and adrenal suppression in patients receiving inhaled corticosteroids for asthma. A potential treatment option is also discussed. Adrenal suppression secondary to inhaled corticosteroids has previously been reported and is often underrecognized. A decrease in linear height velocity has also been associated with inhaled corticosteroids. However, a decrease in height velocity has not been shown to predict adrenal suppression.

CASE STUDY

This case series of 15 patients receiving inhaled corticosteroids for control of asthma were noted to have a decrease in linear growth velocity ultimately associated with adrenal suppression. A change in inhaled corticosteroid to ciclesonide led to recovery of adrenal function without impacting asthma control.

RESULTS

Chart review from a pediatric pulmonology clinic was performed. Growth parameters and laboratory studies were recorded and analyzed. A mean decrease in height standard deviation score in the year prior to diagnosis of adrenal suppression was -0.59, -0.11, and -0.18, in pre-puberty, peri-puberty, and post-puberty patients, respectively. After ciclesonide therapy was initiated, a mean change in height standard deviation score of +0.40, +0.13, and -0.13, was noted for pre-puberty, peri-puberty, and post-puberty patients, respectively. A change in growth velocity of +5.3 cm/yr, +2.1 cm/yr, and -1.9 cm/yr, was noted for pre-puberty, peri-puberty, and post-puberty patients, respectively, after starting ciclesonide.

CONCLUSIONS

Height velocity should be monitored closely during routine asthma visits to identify potential adrenal suppression associated with inhaled corticosteroids use. Ciclesonide is a good option for asthma treatment that allows for adrenal recovery.

Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value

BACKGROUND

Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric work group's results.

METHODS

A work group of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below.

RESULTS

The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.

CONCLUSION

We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.

Current recommendations for the treatment of mild asthma

Patients suffering from mild asthma are divided into intermittent or persistent classes based on frequency of symptoms and reliever medication usage. Although these terms are used as descriptors, it is important to recognize the approach of focusing on asthma control in managing asthma patients. Beta-agonists are considered first-line therapy for intermittent asthmatics. If frequent use of beta-agonists occurs more than twice a week, controller therapy should be considered. For persistent asthma, low-dose inhaled corticosteroids are recommended in addition to reliever medication. Compliance to regular therapy can pose problems for disease management, and while intermittent controller therapy regimens have been shown to be effective, it is imperative to stress the value of regular therapy especially if an exacerbation occurs. It is also important when such an approach is adopted that there is regular re-evaluations of asthma control. This is because regular anti-inflammatory therapy may become necessary if symptoms become more persistent. Other therapies are seldom needed. Antileukotrienes can be considered an option for mild asthma; however, studies have shown that they are not as effective as inhaled corticosteroids. Aside from therapy, patient education, which includes a written action plan, should be a component of the patient's strategy for disease management.

The cumulative burden of oral corticosteroid side effects and the economic implications of steroid use

Oral corticosteroids (OCS) are a key part of therapy regimens for a diverse variety of conditions. Despite their efficacy, they are associated with a wide variety of adverse events. The purpose of this review was to identify the range of adverse events that have been reported to be related to oral corticosteroids, examine the factors that influence their incidence and estimate the economic burden caused by these adverse events. In 61 identified studies, 21 different categories of OCS related adverse events were reported with increased fracture risk being the category most frequently described. Most studies that examined factors linked to the incidence of OCS related adverse events found that dose, age, gender, duration of use, treatment history, smoking habits or cholesterol level were influential in determining risk. Additionally, a cumulative economic analysis of selected adverse events found the annual cost of treating these events in the UK to be at least 165 pounds per patient taking OCS. The clinical and economic burden of OCS related adverse events highlights the need for OCS sparing therapies to be developed.

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.

A comparison of the relative growth velocities with budesonide and fluticasone propionate in children with asthma

There have been no previous large, well-designed direct comparisons of the effects of fluticasone propionate (FP) and budesonide (BUD) on growth in children. This randomised, double-blind study compared the effects on growth of FP and BUD in children aged 6-9 years with persistent asthma. Following a 6-month run-in period (without inhaled corticosteroids), patients with normal growth velocity were randomised to 12 months' treatment with FP 100 micro g bd (n=114) or BUD 200 micro g bd (n=119). Growth velocity was determined by stadiometric height measurement. Lung function, asthma symptoms and use of relief medication were also assessed. Annualised mean growth velocity during run-in was comparable in the two groups (FP: 5.9 cm/yr; BUD: 6.0 cm/yr). During the treatment period, adjusted mean growth velocity was significantly higher in the FP than the BUD group (5.5 cm/yr vs 4.6 cm/yr; P<0.001). Asthma control improved similarly in both treatment groups. Bone mineral density and overnight urinary cortisol:creatinine ratios were similar in the two groups. Drug-related adverse events were reported among 3% of FP-treated children, compared with 2% for BUD. In conclusion, this study demonstrates that FP for childhood asthma has significantly less impact on childhood growth velocity than a therapeutically equivalent dose of BUD.

Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children

BACKGROUND

Anti-leukotrienes agents are currently being studied as alternative first line agents to inhaled corticosteroids in mild to moderate chronic asthma.

OBJECTIVES

To compare the safety and efficacy of anti-leukotriene agents with inhaled glucocorticoids (ICS) and to determine the dose-equivalence of anti-leukotrienes to daily dose of ICS.

SEARCH STRATEGY

We searched MEDLINE (1966 to Aug 2003), EMBASE (1980 to Aug 2003), CINAHL (1982 to Aug 2003), the Cochrane Airways Group trials register, and the Cochrane Central Register of Controlled Trials (August 2003), abstract books, and reference lists of review articles and trials. We contacted colleagues and international headquarters of anti-leukotrienes producers.

SELECTION CRITERIA

Randomised controlled trials that compared anti-leukotrienes with inhaled corticosteroids during a minimal 30-day intervention period in asthmatic patients aged 2 years and older.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the methodological quality or trials and extracted trial data. The primary outcome was the rate of exacerbations requiring systemic corticosteroids. Secondary outcomes included lung function, indices of chronic asthma control, adverse effects and withdrawal rates.

MAIN RESULTS

27 trials (including 1 trial testing two protocols) met the inclusion criteria; 13 were of high methodological quality; 20 are published in full-text. All trials pertained to patients with mild to moderate persistent asthma. Only 3 trials focused on children and adolescents. Trial duration varied from 4 to 37 weeks. In most trials, daily dose of ICS was 400 mcg of beclomethasone or equivalent. Patients treated with anti-leukotrienes were 65% more likely to suffer an exacerbation requiring systemic steroids [Relative Risk 1.65; 95% Confidence Interval (CI) 1.36 to 2.00]. Twenty six (95% CI: 17 to 47) patients must be treated with anti-leukotrienes instead of inhaled corticosteroids to cause one extra exacerbation. Significant differences favouring ICS were noted in secondary outcomes where()the improvement in FEV(1) reached 130 mL [13 trials; 95% CI: 50, 140 mL ]. Other significant benefits of ICS were seen for symptoms, nocturnal awakenings, rescue medication use, symptom-free days, and quality of life. Anti-leukotriene therapy was associated with 160% increased risk of withdrawals due to poor asthma control. Twenty nine (95% CI 20 to 48) patients must be treated with anti-leukotrienes instead of inhaled corticosteroids to cause one extra withdrawal due to poor control. Risk of side effects was not different between groups.

REVIEWERS' CONCLUSIONS

Inhaled steroids at a dose of 400 mcg/day of beclomethasone or equivalent are more effective than anti-leukotriene agents given in the usual licensed doses. The exact dose-equivalence of anti-leukotriene agents in mcg of ICS remains to be determined. Inhaled glucocorticoids should remain the first line monotherapy for persistent asthma.

Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma

BACKGROUND

Anti-leukotriene (AL) agents are being considered as 'add-on' therapy to inhaled corticosteroids (ICS), in chronic asthma.

OBJECTIVES

To examine the safety and efficacy of daily AL plus ICS compared to ICS alone, and determine the corticosteroid-sparing effect of AL when added to ICS in chronic asthma.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL (until August 2003), reference lists of review articles and trials, contacted international headquarters of AL manufacturers and looked at American Thoracic Society and European Respiratory Society meeting abstracts (1998 to 2003).

SELECTION CRITERIA

Randomised placebo-controlled trials of asthmatics aged two years and older with at least one month intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed quality and extracted data independently. Trials were grouped by asthma control at baseline (symptomatic or well-controlled) and dose of ICS in the control group (same or double).

MAIN RESULTS

Of 587 citations, 27 (25 adult and 2 paediatric) trials met inclusion criteria. Sixteen trials were published in full-text and 16 trials reported data in a way that allowed meta-analysis. In symptomatic patients, addition of licensed doses of anti-leukotrienes to ICS resulted in a non-significant reduction in the risk of exacerbations requiring systemic steroids: Relative Risk (RR) 0.64; 95% Confidence Interval (CI) 0.38 to 1.07). A modest improvement group difference in PEF was seen (Weighted Mean Difference (WMD) 7.7 L/min; 95% CI 3.6 to 11.8 L/min) together with decrease in use of rescue short-acting beta2-agonist use (WMD 1 puff/week; 95%CI 0.5 to 2). With only 3 trials comparing the use of licensed doses of anti-leukotrienes with increasing the dose of inhaled glucocorticoids, no firm conclusion can be drawn about the equivalence of both treatment options. In ICS-sparing studies of patients who were well controlled at baseline, addition of anti-leukotrienes produced no overall difference in dose of inhaled glucocorticoids (WMD -21 mcg/d, 95%CI -65, 23 mcg/d), but it was associated with fewer withdrawals due to poor asthma control (RR 0.63, 95% CI 0.42 to 0.95).

REVIEWERS' CONCLUSIONS

The addition of licensed doses of anti-leukotrienes to add-on therapy to inhaled glucocorticoids brings modest improvement in lung function. Although addition of anti-leukotrienes to inhaled glucocorticoids appears comparable to increasing the dose of inhaled steroids, the power of the review is insufficient to confirm the equivalence of both treatment options. Addition of anti-leukotrienes is associated with superior asthma control after glucocorticoid tapering; although the glucocorticoid-sparing effect cannot be quantified at present, it appears modest.

Efficacy and safety of budesonide inhalation powder (Pulmicort Turbuhaler) during 52 weeks of treatment in adults and children with persistent asthma

BACKGROUND

Inhaled corticosteroids are the agents of choice for treating persistent asthma.

OBJECTIVE

To evaluate the long-term efficacy and safety of budesonide inhalation powder (Pulmicort Turbuhaler) in patients with mild to severe persistent asthma.

METHODS

Patients (n=1133) received open-label budesonide (dose range, 100-800 microg b.i.d.) for 52 weeks following 2 weeks to 5 months of treatment in one of four double-blind, placebo-controlled studies. Patients, identified before the double-blind studies, included adults (n=249) not receiving corticosteroids, adults (n=384) and children (n=356) previously maintained on inhaled corticosteroids, and adults (n=144) previously maintained on oral corticosteroids.

RESULTS

Mean forced expiratory volume in 1 sec was 68.2% of predicted normal (n=1133) at baseline (mean from two visits before randomization), 74.4% (n=1132) at the end of double-blind treatment, 81.3% (n=971) at week 52, and 80.1% (n=1125) at last observation (including patients who discontinued early). Sixty-four patients maintained on oral corticosteroids before double-blind treatment entered the open-label study off oral corticosteroids, 58 of whom (91%) remained oral corticosteroid-free throughout the study. There was no evidence of basal or cosyntropin-stimulated hypothalamic-pituitary-adrenal axis function suppression, and the most commonly occurring adverse events were respiratory infection, sinusitis, and pharyngitis.

CONCLUSIONS

During this 52-week, open-label study, budesonide maintained the improved pulmonary function and decreased oral corticosteroid use observed during previous double-blind treatment and was well tolerated, supporting its long-term use in adults and children with mild to severe persistent asthma.

Safety of inhaled corticosteroids in children

Inhaled corticosteroids (ICS) are now first-line therapy for persistent asthma in children. The major safety concerns of long-term ICS therapy for childhood asthma are potential effects on adrenal function, growth, and bone mass. Dosage, type of inhaler device, and individual drug characteristics influence systemic effects of ICS. Sensitive measures of basal adrenal function can show statistically significant changes during ICS therapy, but these do not accurately predict clinically meaningful adrenal axis suppression. Adrenal insufficiency is rare and confined to children receiving high doses of ICS. Dose-related inhibition of growth has been seen in some short- and intermediate-term studies, but long-term studies have found no detrimental effect on final height. ICS therapy has not been associated with significant changes in measurements of bone and bone biomarkers, but more studies of high doses and of therapy in adolescents are needed. Overall, although ICS are the most effective anti-inflammatory treatment available for asthma, high doses of ICS in children are still of concern. The risk of high doses is compounded in children with concomitant allergic conditions that require multiple forms of topical corticosteroids. Benefits of ICS clearly outweigh potential adverse effects and risks associated with poorly controlled asthma. Risk can be minimized by using the lowest effective ICS dose, limiting systemic availability of the drug through proper technique to minimize swallowed drug, and selection of agents with efficient first-path hepatic inactivation of swallowed drug. Adjuvant treatments can reduce the dose of ICS required for asthma control, allowing a reduction in overall systemic exposure for most children with mild-to-moderate persistent asthma. Therefore, these agents should be added to, but should not replace, ICS therapy.

Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma

BACKGROUND

Anti-leukotriene (AL) agents are being considered as "add-on" therapy to inhaled corticosteroids (ICS), in chronic asthma.

OBJECTIVES

To examine the safety and efficacy of daily AL plus ICS compared to ICS alone, and determine the corticosteroid-sparing effect of AL when added to ICS in chronic asthma.

SEARCH STRATEGY

We searched Medline, Embase, Cinahl (until September 2001), reference lists of review articles and trials, contacted international headquarters of AL manufacturers and ATS meeting abstracts (1998-2000).

SELECTION CRITERIA

Randomised placebo-controlled trials of asthmatics aged 2 years and older with at least one month intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed quality and extracted data independently. Trials were grouped by asthma control at baseline (symptomatic or well-controlled) and dose of ICS in the control group (same or double).

MAIN RESULTS

Of 438 citations, 13 (12 adult and 1 paediatric) trials met inclusion criteria. Seven were published in full-text. In symptomatic patients, addition of licensed doses of anti-leukotrienes to ICS resulted in a non-significant reduction in the risk of exacerbations requiring systemic steroids: Relative Risk (RR) 0.61; 95% Confidence Interval (CI) 0.36,1.05). A modest improvement group difference in PEF was seen (Weighted Mean Difference (WMD) 7.71 L/min; 95%CI 2.98, 12.44 L/min) together with beta2-agonist use (WMD= -0.32 puffs/day; 95%CI -0.0.08, -0.56). No trials that compared the use of licensed doses of anti-leukotrienes with doubling-dose of inhaled glucocorticoids could be pooled. In ICS-sparing studies in patients who were well controlled at baseline, addition of anti-leukotrienes produced no overall difference in dose of inhaled glucocorticoids (WMD -44.4 mcg/d, 95%CI -147.9, 59.0 mcg/d), but it was associated with fewer withdrawals due to poor asthma control (RR= 0.56, 95%CI 0.35, 0.89).

REVIEWER'S CONCLUSIONS

There is insufficient evidence to firmly support the use of licensed doses of anti-leukotrienes as add-on therapy to inhaled glucocorticoids. Addition of anti-leukotrienes to inhaled glucocorticoids may slightly improve asthma control, but the available data do not permit this strategy to be recommended as a substitute for increasing the dose of inhaled glucocorticoids. Addition of anti-leukotrienes may be associated with superior asthma control after glucocorticoid tapering, but a glucocorticoid-sparing effect cannot be quantified at present.

Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children

BACKGROUND

Anti-leukotrienes agents are currently being studied as alternative first line agents to inhaled corticosteroids in mild to moderate chronic asthma.

OBJECTIVES

To compare the safety and efficacy of anti-leukotriene agents with inhaled glucocorticoids (ICS) and to determine the dose-equivalence of anti-leukotrienes to daily dose of ICS.

SEARCH STRATEGY

Medline (1966 to Jan 2002), Embase (1980 to Jan 2002), and Cinahl (1982 to Jan 2002) were searched and reference lists of review articles and trials. We contacted colleagues and international headquarters of anti-leukotrienes producers.

SELECTION CRITERIA

Randomised controlled trials that compared leukotriene antagonists with inhaled corticosteroids during a minimal 30-day intervention period in asthmatic patients aged 2 years and older.

DATA COLLECTION AND ANALYSIS

Two reviewers performed assessments of methodological quality and data extraction independently and blindly. The primary outcome was the rate of exacerbations requiring systemic corticosteroids. Secondary outcomes included lung function, indices of chronic asthma control, adverse effects and withdrawal rates.

MAIN RESULTS

14 trials met the inclusion criteria; 10 were of high methodological quality; 8 are published in full-text. All were in mild-to-moderate chronic asthma, Two included children or adolescents. Trial duration was 4 - 37 weeks. In most trials, daily dose of ICS was 400 mcg of beclomethasone-equivalent. Patients treated with anti-leukotrienes were 60% more likely to suffer an exacerbation requiring systemic steroids [12 trials; Relative Risk 1.61; 95% Confidence Interval (CI) 1.15, 2.25]. Significant differences favouring ICS were noted in most secondary outcomes, eg improvement in FEV1 [7 trials; Weighted Mean Difference 120 ml; 95% CI: 80, 170 ml ]; symptom scores [5 trials: Standardized Mean Difference 0.3; 95% CI 0.2, 0.4]. Other significant benefits of ICS were seen for nocturnal awakenings, rescue medication use, and quality of life. Risk of side effects was not different between groups, but anti-leukotriene therapy was associated with 30% increased risk of "withdrawals for any cause" or "withdrawals due to poor asthma control".

REVIEWER'S CONCLUSIONS

For most asthma outcomes, ICS at 400 mcg/day of beclomethasone-equivalent are more effective than anti-leukotriene agents given in the usual licensed doses. The exact dose-equivalence of anti-leukotriene agents in mcg of ICS remains to be determined.

Adult height in women with childhood asthma--a population-based study

PURPOSE

To study adult height in children that grew up with asthma before inhaled steroids became first-line therapy.

METHODS

Data from the Swedish Medical Birth Register (self-reported asthma) and the Hospital Discharge Register (first hospitalization for asthma) were used, to compare adult height for asthmatic and non-asthmatic pregnant women. The analysis was restricted to women in their first full-term pregnancy, born in Sweden between 1960-1974 and of Swedish citizenship.

RESULTS

The mean height of all the women in the study population was 166.7 cm (SD = 8.8, n = 287,750) and of the women who reported asthma 166.5 cm (SD = 6.1, n = 13,059, p < 0.01). The mean height of women first hospitalized because of asthma at age 0-8 years was 165.5 cm (SD = 5.9 cm, n = 555, p < 0.01). Among the asthmatic women, there was no skew distribution of heights.

CONCLUSIONS

Girls with moderate to severe childhood asthma who grew up before inhaled glucocorticosteroids became first-line therapy attained 0.7-1.2 cm lower adult height. The differences in height. while of statistical relevance, are not clinically relevant.

Low-dose inhaled budesonide once or twice daily for 27 months in children with mild asthma

This study is an extended follow-up for 24 months of a 12-week trial to study the long-term clinical efficacy of low-dose inhaled budesonide (BUD) once or twice daily in children with mild asthma. A total of 122 children (mean age 9.7 years, girls/boys; 42/80) with mild asthma (FEV1 103.7% of predicted, reversibility in FEV1 3.5%, and fall in FEV1 after exercise 12.2%), not previously treated with inhaled steroids, were included in a double-blind, randomized, parallel-group study. The children were treated with inhaled BUD 100 or 200 microg administered via Turbuhaler once daily in the morning, 100 microg twice daily, or placebo for 27 months. Exercise and methacholine challenges were performed at 3-month intervals the first year and at 6-month intervals the second year, in a total of seven visits. A significant dose-response effect favoring BUD 200 microg daily (vs 100 microg daily) was found when comparing changes in FEV1, FEF25%, and FEV50%; the fall in FEV1 after an exercise test; and the effect on blood eosinophils. Bronchial hyperreactivity to methacholine decreased significantly on three visits in patients treated with BUD 200 microg daily compared to placebo. Growth rate was not significantly affected except in children aged 7-11 years at baseline after 12 months of treatment. In conclusion, 100 or 200 microg daily of inhaled BUD for 27 months is safe and effective in protecting against exercise-induced asthma and achieving nearly normal lung function. Baseline lung function was not significantly affected in this group of children with mild asthma.

Reduced height in swedish men with asthma at the age of conscription for military service

OBJECTIVE

To investigate the influence of asthma on growth in Swedish children during a period when inhaled corticosteroids (ICS) have been first-line therapy for persistent asthma.

STUDY DESIGN

We analyzed the height of conscripts with and without asthma in the year they turned 18 years old, using Swedish military conscription records from 1983, 1986, 1993, and 1996, and assessed exposure to ICS using prescription records over the same period.

RESULT

The mean height for conscripts without asthma was 179.3 cm (SD = 6.6 cm, n = 164,503) and for conscripts with asthma 178.6 cm (SD = 6.6 cm, n = 8,531, P <.001). The severity of asthma had a negative correlation with height in all study populations (P <.001 in each year tested). Since 1985, increasing numbers of children with asthma have been treated with ICS in Sweden. Sales of ICS for males from birth to age 19 years increased from 68,000 daily doses in 1983 to more than 3, 000,000 in 1995-1996. During this period, there was no statistically significant change in the height difference between conscripts with and without asthma.

CONCLUSION

The introduction of inhaled steroids in Sweden, where budesonide is the predominant medication, has not changed the mean difference in heights between Swedish conscripts with and without asthma.

The effect of inhaled steroids on the linear growth of children with asthma: a meta-analysis

OBJECTIVE

To determine whether inhaled steroid therapy causes delayed linear growth in children with asthma.

DATA SOURCES

Medline (1966-1998), Embase (1980-1998), and Cinahl (1982-1998) databases and bibliographies of included studies were searched for randomized, controlled trials of inhaled steroid therapy in children with asthma that evaluated linear growth.

STUDY SELECTION

Studies were included if they met the following criteria: subjects 0 to 18 years of age with the clinical diagnosis of asthma; subjects randomized to inhaled beclomethasone, budesonide, flunisolide, fluticasone, or triamcinolone versus a nonsteroidal inhaled control for a minimum of 3 months; single- or double-blind; and outcome convertible to linear growth velocity. English- and non-English-language trials were included.

DATA EXTRACTION

Data were extracted using a priori guidelines. Methodologic quality was assessed independently by both authors. Outcome was extracted as linear growth velocity.

RESULTS

Included trials were subgrouped by inhaled steroid. The beclomethasone subgroup, with 4 studies and 450 subjects, showed a decrease in linear growth velocity of 1.51 cm/year (95% confidence interval: 1.15,1.87). The fluticasone subgroup, with 1 study and 183 subjects, showed a decrease in linear growth velocity of.43 cm/year (95% confidence interval:.01,.85). Sensitivity analysis in the beclomethasone subgroup, which evaluated study quality, mode of medication delivery, control medication, and statistical model, showed similar results.

CONCLUSIONS

This meta-analysis suggests that moderate doses of beclomethasone and fluticasone in children with mild to moderate asthma cause a decrease in linear growth velocity of 1.51 cm/year and.43 cm/year, respectively. The effects of inhaled steroids when given for >54 weeks, or on final adult height, remain unknown.

Beclomethasone for asthma in children: effects on linear growth

BACKGROUND

Inhaled steroids play a central role in the management of childhood asthma. There is concern about their side effects, especially on growth. However asthma may also cause growth retardation. Growth rates are not stable, so randomised controlled parallel group studies are needed to assess the impact of inhaled steroids on growth. This review is confine to one inhaled steroid, beclomethasone, that is known to have significant levels of systemic absorption.

OBJECTIVES

To determine whether inhaled beclomethasone cause significant delay in the linear growth of children with asthma.

SEARCH STRATEGY

The Cochrane Airways Group asthma register was searched. Bibliographies from included studies, and known reviews were searched for additional citations. Personal contact with colleagues and researchers working in the field of asthma were made to identify potentially relevant trials.

SELECTION CRITERIA

Randomized, controlled trials comparing the effects of beclamethasone to non-steroidal medication (placebo or non-steroidal therapy) on the linear growth of children with asthma.

DATA COLLECTION AND ANALYSIS

Data related to the clinical outcome "change in growth" were extracted by two reviewers working independently

MAIN RESULTS

One hundred and fifty-nine citations were identified by the search strategy and bibliography review. Three studies met the inclusion criteria. All used beclomethasone 200 mcg twice daily delivered by dry powder Diskhaler to treat children with mild-moderate asthma. Study duration was 7-12 months. In all three studies, a significant decrease in linear growth occurred in children treated with beclomethasone compared to those receiving placebo or non-steroidal asthma therapy. The average decrease, calculated through meta-analysis, was -1.54 cm per year (95% CI -1.15, -1.94).

REVIEWER'S CONCLUSIONS

In children with mild-moderate asthma, beclomethasone 200 mcg twice daily caused a decrease in linear growth of -1.54 cm per year. These studies lasted a maximum of 54 weeks, so it remains unclear whether the decrease in growth is sustained or whether it reverses with 'catch up' after therapy is discontinued. We are unable to comment on growth effects of other inhaled steroids that have potentially less systemic effects. If inhaled steroids are required to control a child's asthma, we recommend using the minimum dose that effectively controls the child's asthma and closely following growth.

Pharmacologic therapy for asthma

Pharmacologic therapy is used to prevent and control asthma symptoms, reduce the frequency and severity of asthma exacerbations, and reverse airflow obstruction. Recommendations in this chapter, based on the 1997 National Asthma Education and Prevention Program Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma, reflect the scientific concept that asthma is a chronic disorder with recurrent episodes of airflow limitation, mucus production, and cough. Asthma medications are categorized into two general classes: long-term-control medications taken daily on a long-term basis to achieve and maintain control of persistent asthma (these medications are also known as long-term preventive, controller, or maintenance medications), and quick-relief medications taken to provide prompt reversal of acute airflow obstruction and relief of accompanying bronchoconstriction (these drugs are also known as reliever or acute rescue medications). Patients with persistent asthma require both classes of medication. Selecting the appropriate pharmacologic therapy to achieve and maintain control of asthma involves several considerations: the medications and their routes of administration, a stepwise approach to managing asthma long-term as a chronic disorder, and the development of an effective clinician-patient partnership strategy where patient education is continuously provided.

Growth in asthmatic children treated with fluticasone propionate. Fluticasone Propionate Asthma Study Group

OBJECTIVE

To determine whether inhaled fluticasone propionate has long-term effects on growth in children with persistent asthma.

STUDY DESIGN

In a double-blind, randomized, parallel-group, multicenter study, 325 prepubescent children with persistent asthma and normal growth rates were treated with placebo or inhaled fluticasone propionate powder 50 microg or 100 microg administered twice daily by a breath-actuated device for 1 year. Growth was evaluated monthly, whereas other safety variables and pulmonary function were evaluated periodically.

RESULTS

The prepubescent patients showed no statistically significant differences in mean height, mean growth velocity, or mean skeletal age between any of the treatment groups at any time. Over a period of 1 year, mean height (+/- SE) increased 6.15 +/- 0.17 cm in the placebo group, 5.94 +/- 0.16 cm in the fluticasone propionate 50 microg group, and 5.73 +/- 0.13 cm in the fluticasone propionate 100 microg group (p = 0.308, overall).

CONCLUSIONS

Prepubescent children treated with fluticasone propionate 50 microg and 100 microg administered twice daily for 1 year grew at rates similar to placebo-treated control subjects and at rates equal to expected growth velocity for age.

Growth during one year of treatment with fluticasone propionate or sodium cromoglycate in children with asthma

The aim of this study was to compare accurately measured growth over 12 months in asthmatic children treated with either fluticasone propionate (FP) 50 micrograms twice daily (b.i.d.) or sodium cromoglycate (SCG) 20 mg four times daily (q.i.d.). After a 2-week run-in, asthmatic children aged 4-10 years from 15 UK centers were randomized in a 3:4 ratio to open-label FP (n = 52) or SCG (n = 70). After 8 weeks, those whose asthma was not adequately controlled were switched from SCG to FP or withdrawn. Standing height was measured (Holtain stadiometry) at baseline, after 8 weeks and at 6 weeks intervals thereafter for 1 year. Morning peak flows (PEFam) were recorded by patients for 2 weeks during baseline, and 1 week before each visit during treatment. Urinary free cortisol (24 h) was measured at baseline, 6 months, and 1 year. After 8 weeks, 22 patients were withdrawn from SCG group (and were switched to FP), and five patients were withdrawn from the FP group due to poor asthma control. A further 21 and 11 patients were withdrawn from the SCG and FP groups, respectively, during the course of the study. There were no significant differences between patients who received FP and SCG for 1 year (n = 34 and n = 26, respectively) in terms of height velocity adjusted for age and gender (HV), or height velocity standard deviation scores adjusted for gender (HVSDS). Mean HV (mean HVSDS) were 6.0 cm/yr (0.1) and 6.5 cm/yr (0.5) for FP and SCG, respectively. There were no treatment differences in mean 24 h urinary free cortisol levels at 6 and 12 months. Mean % predicted PEFam improved over 1 year in both groups but to a greater degree in the FP group. We concluded that growth was normal in mildly asthmatic children receiving FP (50 micrograms bid) for 1 year. There were fewer withdrawals and lung function improved to a greater extent in FP treated patients than in patients receiving SCG.

Salmeterol. A review of its pharmacological properties and clinical efficacy in the management of children with asthma

Salmeterol xinafoate is a selective beta 2-adrenoceptor agonist indicated for the maintenance treatment of adults and children with asthma. When administered as a dry powder or aerosol, salmeterol produces bronchodilation for at least 12 hours and protects against methacholine and exercise-induced bronchoconstriction. Salmeterol is not recommended for the treatment of acute exacerbations of asthma. Recent clinical studies have demonstrated the efficacy and tolerability of inhaled salmeterol in the management of asthma in children. Salmeterol improved symptom control and lung function more effectively than placebo or regularly administered salbutamol. In children who were symptomatic despite regular inhaled corticosteroid therapy, the addition of salmeterol to treatment produced a significant improvement in morning and evening peak expiratory flow and forced expiratory volume in 1 second, and a significant reduction in the incidence of asthma exacerbations compared with placebo. Notably, the long duration of action of salmeterol makes it particularly suitable for the prevention of nocturnal asthma symptoms and exercise-induced asthma (EIA) in children. Current data suggest that salmeterol should not be used as a substitute for corticosteroid therapy in children, but rather as an adjunct to therapy. Thus, salmeterol may be a suitable adjunct to therapy in children with asthma receiving inhaled corticosteroids. In addition, salmeterol also has a potentially important role in the prevention of EIA and nocturnal asthma symptoms.