Inhaled corticosteroids do not prevent subsequent development of asthma

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• Guilbert TW, Morgan WJ, Zeiger RS, Mauger DT, Boehmer SJ, Szefler SJ, et al. Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med 2006;354:1985-97
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Guilbert TW, Morgan WJ, Zeiger RS, Mauger DT, Boehmer SJ, Szefler SJ, et al. Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med 2006;354:1985-97 

Question Among preschool children at high risk for asthma, will inhaled corticosteroids modify the subsequent development of asthma?

Design Randomized, controlled trial.

Setting Multiple centers in the United States.

Participants 285 children ages 2 to 3 years, with a positive asthma predictive index.

Intervention Fluticasone propionate (at a dose of 88 μg twice daily) or masked placebo for 2 years, followed by a 1-year period without study medication.

Outcome The proportion of episode-free days during the observation year.

Main Results No significant differences were seen between the 2 groups in the proportion of episode-free days, the number of exacerbations, or lung function. During the treatment period, use of the inhaled corticosteroid was associated with a greater proportion of episode-free days and a lower rate of exacerbations and of supplementary use of controller medication. In the inhaled-corticosteroid group, the mean increase in height was 1.1 cm less at 24 months (P < .001), but by the end of the trial, the height increase was 0.7 cm less (P = .008).

Conclusions In preschool children at high risk for asthma, 2 years of twice-daily administration of inhaled-corticosteroid therapy controlled symptoms during the treatment period but did not change the development of asthma symptoms or lung function during a third, treatment-free year. These findings do not provide support for a subsequent disease-modifying effect of inhaled corticosteroids after the treatment is discontinued.

Commentary This study by Guilbert et al strengthens the evidence that treatment with inhaled corticosteroids in early life does not alter the natural history of asthma. However, the study provides an imperfect link to the Childhood Asthma Management Program study of older children with asthma,¹ in that it lacks information on the effects of corticosteroids on the growth of lung function and airway responsiveness, which are important phenotypic characteristics related to asthma. Nevertheless, although many of the young children in this study had difficulty performing spirometric tests, the investigators documented that airway resistance measured by oscillometry was improved during treatment but not during the subsequent observation period. Thus the study offers strong evidence supporting the use of twice-daily inhaled corticosteroids for symptomatic control in a select subgroup of children who are at high risk for asthma with an established history of 4 or more wheezing episodes in the first 2 to 3 years of life, as well as additional risk factors for the persistence of wheezing.

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Reference 

1. The Childhood Asthma Management Program Research Group. Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med. 2000;343:1054–1063
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