Switching to Steroid Inhaler in Children
When is it safe to introduce a steroid inhaler to a child on salbutamol? Is there any evidence of ethnic differences in the effectiveness of sodium cromoglycate?
A. S. Ayeni, MD
It has become apparent in recent years that the pathophysiology of asthma is much more complicated than we originally thought. Once considered to be primarily a disease of excessive bronchospasm, and therefore appropriately treated with bronchodilators only, asthma is now known to be primarily an inflammatory disease. The anti-inflammatory effects of oral and inhaled corticosteroids (ICS) in asthma have been well studied. These studies show that ICS decrease the severity of asthma symptoms, improve quality of life, decrease urgent care visits and hospitalizations, and reduce the need for oral corticosteroids as well as improve pulmonary function and reduce airway hyperresponsiveness. Studies that compare ICS with other treatment modalities, such as cromolyn, nedocromil, leukotriene receptor antagonists, and theophylline, are somewhat limited, but the current evidence shows that none of these asthma-treatment modalities appear to be as effective at improving long-term asthma outcomes as ICS. Because studies with ICS in children younger than 5 years are not available, treatment recommendations for this age group are based on expert opinion with available data in older children.
Evidence from multiple trials that followed children for 6 years has shown that treatment with ICS at usual recommended doses does not have frequent, clinically significant or irreversible effects on outcomes, such as vertical growth, bone mineral density, ocular toxicity (ie, cataracts and glaucoma), and hypothalamic-pituitary-adrenal axis suppression. The use of ICS in low-to-medium doses during the "growth years" of childhood may decrease growth velocity (which can result in an approximate 1-cm difference in height during the first year of treatment with ICS), but it appears that this effect does not persist during subsequent years of treatment is not progressive, and large studies suggest that final expected adult height is attained despite long-term treatment with ICS. It is nonetheless appropriate to monitor growth in children being treated with ICS, and if there appears to be a slowing of growth, then the physician should weigh the benefits vs the risks of continuing treatment. It should be pointed out, however, that ICS are recommended as treatment in children of all ages, with the National Institutes of Health-National Asthma Education and Prevention Program (NIH-NAEPP) expert guidelines, when the need for inhaled albuterol exceeds a frequency of twice weekly. Use of ICS has been closely linked to dramatically improved asthma outcomes, and should rarely be withheld over concern regarding the possibility of adverse effects of the drug. ICS should be considered a lifesaving drug for asthma, in both children and adults. Although healthcare providers should always be aware of potential side effects from ICS, their beneficial effects outweigh the small risks in the vast majority of patients with asthma. The reader is referred to the NIH/NAEPP expert guidelines for a concise and thoughtful approach to appropriate use of ICS and other medications used in the treatment of asthma.
Regarding your second question, I am not aware of (nor could I find in the literature) any publications regarding ethnic differences in the response to inhaled sodium cromoglycate.
When is it safe to introduce a steroid inhaler to a child on salbutamol? Is there any evidence of ethnic differences in the effectiveness of sodium cromoglycate?
A. S. Ayeni, MD
It has become apparent in recent years that the pathophysiology of asthma is much more complicated than we originally thought. Once considered to be primarily a disease of excessive bronchospasm, and therefore appropriately treated with bronchodilators only, asthma is now known to be primarily an inflammatory disease. The anti-inflammatory effects of oral and inhaled corticosteroids (ICS) in asthma have been well studied. These studies show that ICS decrease the severity of asthma symptoms, improve quality of life, decrease urgent care visits and hospitalizations, and reduce the need for oral corticosteroids as well as improve pulmonary function and reduce airway hyperresponsiveness. Studies that compare ICS with other treatment modalities, such as cromolyn, nedocromil, leukotriene receptor antagonists, and theophylline, are somewhat limited, but the current evidence shows that none of these asthma-treatment modalities appear to be as effective at improving long-term asthma outcomes as ICS. Because studies with ICS in children younger than 5 years are not available, treatment recommendations for this age group are based on expert opinion with available data in older children.
Evidence from multiple trials that followed children for 6 years has shown that treatment with ICS at usual recommended doses does not have frequent, clinically significant or irreversible effects on outcomes, such as vertical growth, bone mineral density, ocular toxicity (ie, cataracts and glaucoma), and hypothalamic-pituitary-adrenal axis suppression. The use of ICS in low-to-medium doses during the "growth years" of childhood may decrease growth velocity (which can result in an approximate 1-cm difference in height during the first year of treatment with ICS), but it appears that this effect does not persist during subsequent years of treatment is not progressive, and large studies suggest that final expected adult height is attained despite long-term treatment with ICS. It is nonetheless appropriate to monitor growth in children being treated with ICS, and if there appears to be a slowing of growth, then the physician should weigh the benefits vs the risks of continuing treatment. It should be pointed out, however, that ICS are recommended as treatment in children of all ages, with the National Institutes of Health-National Asthma Education and Prevention Program (NIH-NAEPP) expert guidelines, when the need for inhaled albuterol exceeds a frequency of twice weekly. Use of ICS has been closely linked to dramatically improved asthma outcomes, and should rarely be withheld over concern regarding the possibility of adverse effects of the drug. ICS should be considered a lifesaving drug for asthma, in both children and adults. Although healthcare providers should always be aware of potential side effects from ICS, their beneficial effects outweigh the small risks in the vast majority of patients with asthma. The reader is referred to the NIH/NAEPP expert guidelines for a concise and thoughtful approach to appropriate use of ICS and other medications used in the treatment of asthma.
Regarding your second question, I am not aware of (nor could I find in the literature) any publications regarding ethnic differences in the response to inhaled sodium cromoglycate.
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