Giovanna Ventura,
MD
Institute of Child Health Burlo Garofolo, University of Trieste, Italy,
Giorgio Longo MD
Send letter to journal:
Re: Inhaled Corticosteroids in Recurrent Asthma in Children
gioviventura{at}gmail.com Giovanna Ventura, et al.
|
We greatly appreciated Gary Rachelefsky's huge work published on
Pediatrics in January 2009 (1). We agree with all that's stated in the
summary, particularly that asthma, notably in children, is a complex and
heterogeneous disease in which many factors affect impairment and risk.
Nevertheless, we cannot agree with the algorithm that the Author suggests.
In fact, if we don't clarify the exact meaning of "positive" and "no clear
positive response", we may end up treating the whole population of
preschool recurrent viral wheezers with inhaled corticosteroids (ICSs) or,
what's even worse, we may be induced to “consider alternative
diagnoses/therapies” at the time of the first exacerbation of viral
wheezing. We mustn't forget that, actually, in preschool age viral
respiratory tract infections are the most common trigger factor for asthma
exacerbation (2), and in atopic children as well. In everyday practice,
along with clinical trials, ICSs treatment is associated only with a
reduction of exacerbations if compared to placebo (3) or simply with a
trend towards later onset of "time to first exacerbation" (4). Studies in
preschool children with multiple-trigger wheeze have reported only a
partial reduction in exacerbations by approximately 50% (5, 6) and
maintenance therapy with low dose inhaled corticosteroids -in atopic
subjects or in those with familiarity for atopy as in non-atopic subjects-
was not more effective than placebo in reducing the proportion of episodes
requiring oral corticosteroids or hospital admission (7). The same
objection can be addressed to the National Asthma Education and Prevention
Program Guidelines where the Expert Panel recommends to consider stepping
up of maintenance therapy if there is a history of one or more
exacerbations in the past year (8). Considering what goes on in real life,
we believe that exacerbations of viral wheezing in preschool age
children's asthma, particularly non-severe exacerbations, must not be
uncritically considered a risk domain requiring an upgrade or prolongation
of maintenance therapy.
1. Rachelefsky G. Inhaled corticosteroids and asthma control in children:
assessing impairment and risk. Pediatrics 2009;123:353-66.
2. Lemanske RF Jr. Viruses and asthma: Inception, exacerbation, and
possible prevention. J Pediatr. 2003;142:S3-7.
3. Roorda RJ, Mezei G, Bisgaard H, Maden C. Response of preschool children
with asthma symptoms to fluticasone propionate. J Allergy Clin Immunol.
2001;108:540-6.
4. Nayak A, Lanier R, Weinstein S, Stampone P, Welch M. Efficacy and
safety of beclomethasone dipropionate extrafine aerosol in childhood
asthma: a 12-week, randomized, double-blind, placebo-controlled study.
Chest 2002;122:1956-65.
5. de Blic J, Delacourt C, Le Bourgeois M, Mahut B, Ostinelli J, Caswell
C, Scheinmann P. Efficacy of nebulized budesonide in treatment of severe
infantile asthma: a double-blind study. J Allergy Clin Immunol. 1996
Jul;98(1):14-20
6. Bisgaard H, Gillies J, Groenewald M, Maden C. The effect of inhaled
fluticasone propionate in the treatment of young asthmatic children: a
dose comparison study. Am J Respir Crit Care Med. 1999;160:126-31.
7. McKean M, Ducharme F. Inhaled steroids for episodic viral wheeze of
childhood.Cochrane Database Syst Rev. 2000;(2):CD001107.Chest. 2002
Dec;122(6):1956-65.
8. National Asthma Education and Prevention Program. Expert Panel Report
3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD:
National Institutes of Health; 2007. Available at:
www.nhlbi.nih.gov/guidelines/asthma.
Conflict of Interest:
None declared |
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