Children aged 5-12 yrs

Step 1: Mild intermittent asthma

Prescribe an inhaled short-acting beta 2 agonist as short-term reliever therapy for all patients with symptomatic asthma.

Patients with high usage of inhaled short-acting beta2 agonists should have their asthma management reviewed.

Step 2: introduction of regular preventer therapy

Inhaled steroids are the recommended preventer drug for adults and children for achieving overall treatment goals.

Inhaled steroids should be prescribed for patients with recent exacerbations, nocturnal asthma, impaired lung function or using inhaled beta2 agonists more than once a day.

Starting dose of inhaled steroids

Start patients at a dose of inhaled steroids appropriate to the severity of disease.

A reasonable starting dose will usually be 200 mcg per day.

Titrate the dose of inhaled steroid to the lowest dose at which effective control of asthma is maintained

Frequency of dosing of inhaled steroids

Give inhaled steroids initially twice daily.

Once a day inhaled steroids at the same total daily dose can be considered if good control is established.

Safety of Inhaled Steroids

Monitor children's height on a regular basis.

Consider the possibility of adrenal insufficiency in any child maintained on inhaled steroids presenting with a decreased level of consciousness; blood glucose levels should be checked urgently. Consider whether intramuscular (IM) hydrocortisone is required.

OTHER PREVENTER THERAPIES

Inhaled steroids are the first choice preventer drug. Alternative, less effective preventer therapies in patients taking short-acting beta2 agonists alone are:

• Cromones
• (have an inconvenient dosing frequency)
• sodium cromoglycate is ineffective in children Evidence level 1+
• nedocromil sodium is of benefit in 5-12 year olds Evidence level 1+
• Leukotriene receptor antagonists have some beneficial clinical effect (and an effect on eosinophilic inflammation) Evidence level 1++
• Theophyllines have some beneficial effect (side-effects are more common and monitoring of plasma levels is required). Evidence level 1+
• Long-acting inhaled beta2 agonists have some beneficial effects but they are not recommended as first line preventer therapy. Evidence level 1+
• Antihistamines and ketotifen are ineffective. Evidence level 1++

Step 3: add-on therapy

Carry out a trial of other treatments before increasing the inhaled steroid dose above 400 mcg/day in children.

In children taking inhaled steroids at a dose of 400 mcg/day the following interventions are of value:

The first choice as add-on therapy to inhaled steroids in adults and children (5-12 years) is an inhaled long-acting beta2 agonist.

If asthma control remains sub-optimal after the addition of an inhaled long-acting beta2 agonist then the dose of inhaled steroids should be increased to 400 mcg/day in children (5-12 years).

If control is still inadequate after a trial of LABA and after increasing the dose of inhaled steroid, consider a sequential trial of add-on therapy, i.e. leukotriene receptor antagonists, theophyllines.

Step 4: poor control on moderate dose of inhaled steroid + add-on therapy: addition of fourth drug

If control remains inadequate on 400 mcg daily (children) of an inhaled steroid plus a long-acting beta2 agonist, consider the following interventions:

• increasing inhaled steroids to 800 mcg/day (children 5-12 years)
• leukotriene receptor antagonists
• theophyllines
• slow release beta2 agonist tablets, though caution needs to be used in patients on long-acting beta2 agonists.

There are no controlled trials indicating which of these is the best option.

If a trial of an add-on treatment is ineffective, stop the drug (or in the case of increased dose of inhaled steroid, reduce to the original dose).

Before proceeding to step 5, consider referring patients with inadequately controlled asthma, especially children, to specialist care.

Step 5: continuous or frequent use of oral steroids

PREVENTION AND TREATMENT OF STEROID TABLET-INDUCED SIDE-EFFECTS

Patients on long-term steroid tablets (e.g. longer than three months) or requiring frequent courses of steroid tablets (e.g. three to four per year) will be at risk of systemic side-effects:

• Blood pressure should be monitored
• Diabetes mellitus may occur.
• Osteoporosis commonly occurs and should be monitored and treated (see the British Osteoporosis Society guidelines).
• Growth should be monitored in children.
• Cataracts should be screened for in children.

STEROID TABLET-SPARING MEDICATION

In children aged 5-12, consider very carefully before going above a dose of 1000 mcg/day.

There is a role for a trial of treatment with long-acting beta2 agonists, leukotriene receptor antagonists, and theophyllines for about six weeks. They should be stopped if no improvement in steroid dose, symptoms or lung function is detected.

Immunosuppressants, (methotrexate, cyclosporin and oral gold) may be given as a three month trial, once other drug treatments have proved unsuccessful. Their risks and benefits should be discussed with the patient and their side-effects carefully monitored. Treatment should be in a centre with experience of using these medicines.

(No evidence for Colchicine and intravenous immunoglobulin or continuous subcutaneous terbutaline infusion )

Stepping down

Stepping down therapy once asthma is controlled is recommended, but often not implemented leaving some patients over-treated. There is little evidence regarding the most appropriate way to step down treatment.

Regular review of patients as treatment is stepped down is important. When deciding which drug to step down first and at what rate, the severity of asthma, the side-effects of the treatment, the beneficial effect achieved, and the patient's preference should all be taken into account.

Patients should be maintained at the lowest possible dose of inhaled steroid. Reduction in inhaled steroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every three months, decreasing the dose by approximately 25-50% each time.

Specific management problems

ONSET OF EXACERBATION OF ASTHMA

Although recommended for both adults and children in previous guidelines and as part of asthma action plans, doubling the dose at the time of an exacerbation is of unproven value. In adult patients on a low dose (200 mcg) of inhaled steroids, a five-fold increase in dose at the time of exacerbation leads to a decrease in the severity of exacerbations. This five-fold increase should not be extrapolated to higher doses of inhaled steroids.

EXERCISE-INDUCED ASTHMA

For most patients, exercise-induced asthma is an expression of poorly controlled asthma and regular treatment including inhaled steroids should be reviewed.

Long-acting beta2 agonists and leukotriene antagonists provide more prolonged protection than short-acting beta2 agonists, but a degree of tolerance develops with LABA particularly with respect to duration of action. No tolerance has been demonstrated with leukotriene receptor antagonists. (No evidence in children)

If exercise is a specific problem in patients taking inhaled steroids who are otherwise well controlled, consider the following therapies:

• leukotriene receptor antagonists
• long-acting beta2 agonists
• cromones
• oral beta2 agonists
• theophyllines
• Immediately prior to exercise, inhaled short-acting beta2 agonists are the drug of choice.