PURPOSE OF THE STUDY.
To assess the risk of asthma exacerbation in children with asthma treated with various controller medications, including inhaled corticosteroids (ICS), leukotriene antagonists (LTRA), and ICS/long-acting β-agonist combinations (ICS-LABA).
The study subjects included 26 191 controller-naive asthmatic children aged 4 to 17 years with uncontrolled asthma defined as at least 1 previous asthma exacerbation in the preceding year requiring an ED visit, hospitalization, or a short course of oral corticosteroids. Subjects were recruited from the databases of 6 private health plans (59%) and from the Tennessee Medicaid population (41%).
This was a retrospective cohort study of children with uncontrolled asthma who were dispensed an ICS, LTRA, or ICS-LABA. The primary outcome was ED visits, hospitalizations, or oral corticosteroid use during the 365 days after initiation of controller medication. Adherence was assessed by examining the number of refills after the initial fill. Statistical methods were used to adjust for confounding variables. Race, type of controller medications, and rates of exacerbations differed between subjects in the private health plans and the Tennessee Medicaid populations, which were therefore analyzed separately.
In the Medicaid population, initial dispensing was an LTRA in 55%, ICS in 38% and ICS-LABA in 7%. Subjects who filled an LTRA and ICS-LABA were less likely to experience an asthma exacerbation (14% and 17%, respectively) than subjects who filled an ICS (21%). Adherence was poor with no refills in 46% of subjects on ICS-LABA, 40% of subjects on ICS, and 33% of subjects on LTRA. In the subgroup of subjects with a diagnosis of allergic rhinitis, treatment with an LTRA resulted in fewer ED visits compared with treatment with ICS. In the private health plans, initial dispensing was an ICS in 87%, an LTRA in 8%, and an ICS-LABA in 5%. There was no difference in the frequency of ED visits among the 3 groups (6%). Adherence was also poor with no refills in 50% of subjects on ICS, 45% of subjects on ICS-LABA, and 35% of subjects on LTRA.
Children who initiated LTRA had similar rates of asthma exacerbations as children who initiated ICS.
It is difficult to compare the results of this “real-life” study to those of randomized controlled trials, which have consistently showed superiority of ICS over LTRA for asthma control in children. It is interesting that the concomitant presence of allergic rhinitis resulted in decreased ED visits in subjects treated with an LTRA compared with ICS in the Medicaid population. An important message for the practicing pediatrician is the confirmation of poor adherence to prescribed regimens. Ultimately, and as with most other diseases, treatment of asthma should be individualized. Future studies are needed to identify clinical or biomarkers that would help predict treatment responsiveness to these different classes of controller medications. Until then, the choice of medication will continue to be adjusted based on the level of asthma control achieved.
- Copyright © 2015 by the American Academy of Pediatrics