Inhaled corticosteroids and growth in children

Challenges in evaluating controller asthma therapy in children

Clinical data about the efficacy and safety of controller medications for pediatric patients of all ages are limited, especially when compared with the amount of data available for medications for adults. The considerable data collected so far in adults about these therapeutic agents need to be confirmed in children because pharmacologic profiles will not necessarily be the same for children. Clinical research studies need to include younger populations so that the necessary information can be available for physicians who want to use controller therapy for their pediatric patients. Special challenges confront the pharmaceutical companies and the research investigators who undertake these clinical studies, but such challenges are surmountable.

Longitudinal growth in infants and young children treated with budesonide inhalation suspension for persistent asthma

BACKGROUND

Results of recent growth studies suggest that inhaled glucocorticosteroids may affect growth in children.

OBJECTIVE

Three 52-week, open-label extension studies (studies A, B, and C) were conducted to compare the effects of budesonide inhalation suspension (BIS) with conventional asthma therapy (CAT) on long-term safety, including intermediate-term growth, in 3 different pediatric asthma populations.

METHODS

Pediatric asthma patients (ages 6 months to 8 years) from 3 multicenter, randomized, 12-week, double-blind, placebo-controlled studies were eligible to enroll in the 52-week, open-label extension studies. The extension studies were multicenter, randomized, open-label, active-controlled, parallel-group studies performed at 26 centers in the United States. Subjects in each extension study were randomized in a 2:1 ratio to receive either BIS or CAT. BIS was initially administered at a dose of 0.5 mg once (studies A and C) or twice daily (study B), with attempts made at each clinical visit to gradually reduce the dose to the minimum effective dose that maintains asthma control, as judged by the investigator. CAT consisted of any available therapy for asthma, including inhaled glucocorticosteroids in studies B and C only. Height SD scores, growth velocity, and skeletal age (only in studies B and C) were examined.

RESULTS

In total, 670 subjects were randomized; 223 subjects received CAT and 447 received BIS. Mean ages at entry were 63.0 months and 60.9 months in CAT and BIS groups, respectively. Median total daily doses of BIS ranged from 0.5 to 1. 0 mg and the mean duration of treatment exposure was 304 +/- 119 days and 342 +/- 83 days in CAT and BIS groups, respectively. Changes in height SD scores differed significantly between the BIS and CAT groups in study A (-0.19, P =.003), and there was a small, statistically significant decrease in growth velocity (-0.8 cm/y, P =.002) in the BIS-treated group compared with the CAT group. No significant differences were observed between BIS and CAT groups in the changes in height SD scores or in growth velocities in studies B (+0.10 and +0.7 cm/y, respectively) and C (+0.12 and +0.8 cm/y, respectively). No differences in skeletal age were observed between BIS and CAT groups in studies B and C.

CONCLUSION

There was a small, statistically significant decrease in growth velocity in the BIS-treated group compared with the CAT group in the study (study A) where inhaled glucocorticosteroid use was prohibited before entry and in the CAT group during the study. In the studies (B and C) where inhaled glucocorticosteroids were allowed in the CAT group, no differences were observed in height SD scores or growth velocity. The clinical relevance of these effects, including impact on final adult height, remain to be determined in prospectively planned studies that assess growth in children.

Atopic diseases and upper respiratory infections

This article reviews information on the topics of asthma, allergic rhinitis, atopic dermatitis, food allergy, and upper respiratory infections. The asthma section includes a review of inhaled steroids and their potential side effects. New findings on the pathogenesis, triggers, and therapies of atopic dermatitis and new insights into food hypersensitivity reactions are presented. Recent publications in the areas of allergic rhinoconjunctivitis and upper respiratory infections are also reviewed.

What is new in asthma: new dry powder inhalers

Asthma affects an estimated 4.8 million children. The pressurized metered-dose inhaler (pMDI), despite problems associated with its use and concern that most of these inhalers contain ozone-damaging chlorofluorocarbons (CFCs), is currently the device most frequently used to deliver inhaled medication. Concerns regarding pMDIs that contain CFCs have led to further development of alternative delivery devices, including CFC-free pMDIs, breath-actuated devices, and dry powder inhalers (DPIs). Advantages and disadvantages of these devices are discussed briefly, with emphasis on the new DPIs. A brief overview of their safety, efficacy, and acceptance by patients is presented. DPIs have the potential to become important devices for administration of inhaled medication in pediatric asthma management.