Regular use of inhaled corticosteroids controls symptoms of mild persistent asthma, but with growth effect
Article Outline
- Turpeinen M, Nikander K, Pelkonen AS, Syvänen P, Sorva R, Raitio H, Malmberg P. Daily versus as-needed inhaled corticosteroid for mild persistent asthma (The Helsinki early intervention childhood asthma study). Arch Dis Child 2008;93:654-9
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Turpeinen M, Nikander K, Pelkonen AS, Syvänen P, Sorva R, Raitio H, Malmberg P. Daily versus as-needed inhaled corticosteroid for mild persistent asthma (The Helsinki early intervention childhood asthma study). Arch Dis Child 2008;93:654-9
Question Among children with mild persistent asthma, is the use of daily versus as-needed inhaled budesonide more effective in controlling asthma symptoms?
Design Randomized controlled trial.
Setting Helsinki University Hospital, Finland.
Participants One hundred seventy-six children, aged 5 to 10 years with newly detected asthma.
Intervention Children were randomized to 1 of 3 treatment groups: (1) continuous budesonide (400 mg twice daily for 1 month, 200 mg twice daily for months 2 to 6, 100 mg twice daily for months 7 to 18); (2) budesonide, identical treatment to group 1 during months 1 to 6, then budesonide for exacerbations as needed for months 7 to 18; and (3) disodium cromoglycate (DSCG) 10 mg 3 times daily for months 1 to 18. Exacerbations were treated with budesonide 400 mg twice daily for 2 weeks.
Outcomes Lung function, the number of exacerbations, and growth.
Main Results Compared with DSCG the initial regular budesonide treatment resulted in significantly improved lung function, fewer exacerbations, and a small but significant decline in growth velocity. After 18 months, however, the lung function improvements did not differ between the groups. During months 7 to 18, patients receiving continuous budesonide treatment had significantly fewer exacerbations (mean 0.97), compared with 1.69 in group 2 and 1.58 in group 3. The number of asthma-free days did not differ between regular and intermittent budesonide treatment. Growth velocity was normalized during continuous low-dose budesonide and budesonide therapy given as needed. The latter was associated with catch-up growth.
Conclusions Regular use of budesonide afforded better asthma control but had a more systemic effect than did use of budesonide as needed. The dose of inhaled corticosteroid (ICS) could be reduced as soon as asthma is controlled. Some children do not seem to need continuous ICS treatment.
Commentary This study addresses an important question of whether intermittent use of ICS in children with mild persistent asthma can achieve similar control of their symptoms as the continuous use of ICS with potentially fewer side effects. These results replicate those found by Boushey et al1 in a similar study performed in adults with mild asthma. There was no significant difference in peak expiratory flow (PEF) measurements between continuous and intermittent ICS or DSCG group at any time point. However, the use of PEF measurements as an asthma outcome has been recently questioned given its variability and lack of correlation with other outcomes. Turpeinen et al2 also did not demonstrate difference between the groups in pulmonary function. Conversely, the clinical burden of asthma (symptom-free days, number of exacerbations, and time to first exacerbation) was significantly decreased in children treated with continuous ICS compared with intermittent ICS and DSCG treatment groups. It can be argued that clinical symptom burden may be the most relevant measures of childhood asthma control given the number of children with persistent asthma that have normal or near-normal lung function.2 Children treated with continuous ICS demonstrated a significantly decreased mean height velocity after 18 months of the study compared with children treated with DSCG. It should be noted that the height difference was small (1 cm) and similar to the difference found in other studies of children with persistent asthma treated with ICS.2 Of note is that the study included only Caucasian children, so the results may not be generalized to a non-Caucasian population. Thus the results of the study confirm the results from previous studies that continuous treatment with ICS is associated with significantly better asthma control than treatments with DSCG or intermittent treatment. In making the decision to use continuous ICS in children with asthma, the burden of the disease should be weighed against the potential side effects.
References
PII: S0022-3476(08)00898-6
doi:10.1016/j.jpeds.2008.10.024
© 2009 Mosby, Inc. All rights reserved.
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