LABA step-up therapy best for poorly controlled childhood asthma
MedWire News: Treatment with a long-acting beta-agonist (LABA) is the most likely step-up therapy to illicit a good response among children with asthma that remains poorly controlled despite taking low-dose inhaled corticosteroids (ICSs), say researchers.
Writing in the New England Journal of Medicine, Robert Lemanske (University of Wisconsin School of Medicine and Public Health, Madison, USA) and colleagues explain that “uncontrolled asthma occurs in many children who receive treatment with low-dose ICSs.”
But they add: “The few data that are available to guide practitioners about how to treat children whose asthma is poorly controlled while they are receiving low-dose ICSs are inconsistent.”
To identify the most effective treatment for such children, the team assigned 182 children, aged 6–17 years, with uncontrolled asthma to receive each of three step-up therapies in random order for a total period of 48 weeks, with each of the three treatment periods lasting for 16 weeks.
Therapies included in the trial consisted of fluticasone 250 µg twice daily (ICS step-up), fluticasone 100 µg plus 50 µg of a long-acting beta-agonist twice daily (LABA step-up), and fluticasone 100 µg twice daily plus 5 or 10 mg of a leukotriene-receptor antagonist daily (LTRA step-up).
A composite of three outcomes – exacerbations, asthma-control days, and FEV1 – was used to assess the effectiveness of each step-up regimen and the frequency of differential responses.
In total, 157 children completed all three study periods, and 165 completed two study periods, permitting assessment of the differential response.
Of the 165 children who completed at least two treatment periods, 161 had differential responses to the step-up therapies.
Analysis revealed that LABA step-up therapy was most likely to illicit the best response, at a relative probability (RP) of 1.6 compared with LTRA step-up therapy, and a RP of 1.7 compared with ICS step-up therapy.
The researchers also found that race or ethnic group significantly predicted patterns of differential response. Hispanic and non-Hispanic White patients were most likely to have a best response to LABA step-up therapy and least likely to have a best response to ICS step-up. Black patients were equally likely to have a best response to LABA or ICS step-up therapy, but were less likely than the other race/ethnic groups to have a best response to LTRA step-up therapy.
Lemanske and team conclude: “Nearly all the children had a differential response to each step-up therapy.
“LABA step-up was significantly more likely to provide the best response than either ICS or LTRA step-up. However, many children had a best response to ICS or LTRA step-up therapy, highlighting the need to regularly monitor and appropriately adjust each child's asthma therapy.”
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By Mark Cowen