Asthma Management Handbook

Stepping down treatment in children aged 6 years and over

Recommendations

If symptoms have been well controlled for at least 6 months in a child taking regular inhaled corticosteroid treatment, consider reducing the dose.

Monitor symptom control and perform spirometry within 4–6 weeks after stepping down.

Do not attempt to step down treatment at the start of the school year or during the child’s peak asthma season (if there is a predictable seasonal pattern).

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 20101

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If symptoms have been well controlled for at least 6 months in a child taking regular treatment with a combination of inhaled corticosteroid and long-acting beta2 agonist, consider halving the dose.

If the inhaled corticosteroid dose is already low, replace inhaled corticosteroid plus long-acting beta2 agonist with low-dose inhaled corticosteroid alone.

Monitor symptom control within 4–6 weeks after stepping down.

Do not attempt to step down treatment at the start of the preschool year or during the child’s peak asthma season (if there is a predictable seasonal pattern). Take into account previous treatment response, the result of any previous attempts to step down, and changes in the child’s environment that could affect exposure to triggers.

How this recommendation was developed

Consensus recommendation following inconclusive literature search

Based on clinical experience and expert opinion after literature review yielded insufficient evidence for an evidence-based recommendation

Key evidence considered:

  • Akashi et al. 20162
  • Rank et al. 20153
  • Rank et al. 20134

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If symptoms are well controlled for at least 6 months on the lowest available inhaled corticosteroid dose, consider stopping treatment.

Monitor symptom control and perform spirometry within 4–6 weeks after stepping down.

Do not attempt to step down treatment at the start of the school year or during the child’s peak asthma season (if there is a predictable seasonal pattern).

How this recommendation was developed

Consensus recommendation following inconclusive literature search

Based on clinical experience and expert opinion after literature review yielded insufficient evidence for an evidence-based recommendation

Key evidence considered:

  • Ciółkowski et al. 20145
  • Peters et al. 20076
  • Rank et al. 20137
  • van Asperen et al. 20101

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More information

Stepping down preventer treatment in children

Stepping down can be considered when asthma has been well controlled for 6 months (depending on severity of previous symptoms). This will help identify the minimal dose or regimen needed to maintain control and may minimise the risk of treatment-related adverse effects and help identify the minimal dose or regimen needed to maintain control.

Children who have stable asthma are at increased risk of a flare-up when stepping down treatment, so close monitoring is needed. Stepping down should not be attempted at the beginning of the school year.6

Stepping down from regular inhaled corticosteroid

For children already taking the lowest available dose, options are stop preventer treatment entirely, or switch to montelukast. Few studies have compared different options for stepping down.

Children may be at higher risk of a flare-up or loss of asthma control after stopping low-dose inhaled corticosteroid treatment.7 7, 8

Stepping down from regular inhaled corticosteroid plus long-acting beta-2 agonist

Options for stepping down from regular treatment with a combination inhaled corticosteroid and long-acting beta2 agonist are to reduce the inhaled corticosteroid dose or switch to inhaled corticosteroid only (i.e. discontinue the long-acting beta2 agonist).

There is insufficient evidence from randomised trials on which to base recommendations on whether and how to discontinue long-acting beta2 agonist treatment in children once good asthma control has been achieved with the combination of inhaled corticosteroid and long-acting beta2 agonist.9

In a study of children aged 4–11 years whose asthma was well controlled while using a combination of inhaled corticosteroid and long-acting beta2-agonist, stepping down to inhaled corticosteroid monotherapy was associated with a higher rate of flare-ups than continuing on combination therapy.10

In a study of children aged 5–15 years with well-controlled asthma, halving the inhaled corticosteroid component and discontinuing the long-acting beta2 agonist had equivalent outcomes for asthma symptoms and lung function.11

In a study of children with asthma well controlled on twice-daily fluticasone propionate, switching to montelukast was associated with a higher rate of treatment failure and poorer asthma control than halving the fluticasone dose and adding salmeterol.12

Stepping down from montelukast

In children taking montelukast, treatment can be stopped abruptly.

Asthma control should be monitored and the child’s written asthma action plan updated to ensure parents/carers know how to manage symptoms.

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Inhaled corticosteroids for children: adverse effects

Local adverse effects

Hoarseness and pharyngeal candidiasis are not commonly reported among preschool children or school-aged children talking inhaled corticosteroids. 13, 1, 14

Topical effects can be reduced by use of spacer devices (which reduce oropharyngeal deposition), and by mouth-rinsing and spitting after use.1 Immediate quick mouth-rinsing removes more residual medicine in the mouth than delayed rinsing.15

There is limited evidence that inhaled asthma medication can affect dental health.1, 16 Mouth rinsing might reduce this risk.

Systemic adverse effects

Systemic effects of inhaled corticosteroids in children depend on the dose, but clinically significant adverse effects are uncommon.1

The use of spacers and mouth rinsing will not reduce systemic effects, but the use of a spacer may increase efficacy so that a lower dose is required.

Growth

Short-term suppression of linear growth has been demonstrated in children taking inhaled corticosteroids.17,18 The effect seems to be maximal during the first year of therapy and only one study has reported an effect in subsequent years of treatment.18 A Cochrane systematic review concluded that regular use of inhaled corticosteroid at low or medium daily doses is associated with a mean reduction of 0.48 cm per year in linear growth velocity and 0.61 cm less gain in height during 1 year of treatment in children with mild to moderate persistent asthma.18

One study of patients who participated in a clinical trial of inhaled corticosteroids as children, reported a reduction in adult height of approximately 1 cm,17, 19, 20, 21 whereas several studies have reported that children taking inhaled corticosteroids attained normal adult height.22, 23, 24

The effect is dose-dependent20,21 and may be more likely in children who begin inhaled corticosteroid treatment before age 10.19

Other factors affect growth in children with asthma. Uncontrolled asthma itself reduces growth and final adult height.25 One study found that inhaled corticosteroid equivalent to budesonide 400 microg/day affected growth less than low socioeconomic status.24

Bone density

Inhaled corticosteroids have not been associated with effects on bone density or fractures in children. 1 However, data from a recent study in Australia suggested asthma itself is associated with increased incidence of fractures in children, independent of medication.26

Given that the total dose of corticosteroids (both inhaled corticosteroids and oral corticosteroids) influences bone health, the aim of asthma management is to maintain symptom control using the lowest inhaled corticosteroid dose required, and to avoid repeated courses of oral corticosteroids.

Adrenal suppression

Biochemical testing in a research setting suggests that hypothalamic–pituitary–adrenal axis suppression may occur in up to two-thirds of children treated with inhaled corticosteroids, and may occur at even low doses.27 The risk is higher among children receiving concomitant intranasal steroids and those with lower body mass index,27 and is influenced by genetics.28

Clinical adrenal insufficiency in children taking inhaled corticosteroids is rare but has been reported, 29, 30, 31 including cases in Australia.31 Most cases have involved children given more than 500 microg per day fluticasone propionate.29

Adrenal suppression is associated with hypoglycaemia, hypotension, weakness, failure to grow, and is potentially fatal. Hypothalamic–pituitary–adrenal axis suppression may not be detected until adrenal crisis is precipitated by physical stress.32

Written information (e.g. a steroid alert card) can be prepared for children receiving long-term high-dose inhaled corticosteroids. Parents/carers can be instructed to present the card if the child ever needs to go to the emergency department (for any reason) or be admitted to hospital. A steroid alert card should state that child has asthma and the inhaled corticosteroid dose. A medical alert bracelet could also be considered.

There are no nationally accepted protocols for routine assessment of adrenal function in primary care because it has not yet been possible to identify precisely which children should be tested, to interpret test results reliably, to identify the appropriate interval for retesting, and because a clinical benefit has not been clearly demonstrated.

Regular monitoring of height might help detect adrenal suppression, based on the findings of a study in which a reduction in linear growth velocity occurred before adrenal suppression.33

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (microg)

Low

High

Beclometasone dipropionate

100–200

>200 (maximum 400)

Budesonide

200–400

>400 (maximum 800)

Ciclesonide

80–160

>160 (maximum 320)

Fluticasone propionate

100–200

>200 (maximum 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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Approaches to assessment and monitoring of asthma control in children

Assessment of asthma control in children is based mainly on:

  • recent asthma symptom control (assessed by the frequency and severity of symptoms between flare-ups 
  • the degree to which asthma symptoms affect daily activities such as interference with physical activity or missed school days)
  • the frequency of flare-ups
  • spirometry in children who are able to perform the test reliably.

Standardised questionnaires

Questionnaire-based instruments have been validated for assessing asthma control in children:

Lung function tests

Frequent spirometry to guide asthma treatment in children has not been shown to achieve superior outcomes to symptom-based treatment.[REFERENCE1739] Current evidence does not support use of home spirometers to guide asthma treatment in children.39 However, low FEV1 predicts clinically significant flare-ups, so spirometry should be performed at asthma reviews for children who are old enough to do the test.
The quality and utility of spirometry depends on the skill, clinical expertise and experience of the person doing and interpreting spirometry.

The results of one study in children aged 6–16 years with moderate atopic asthma suggest that asthma treatment guided by airway hyperresponsiveness (measured by bronchial provocation testing) may have a benefit over symptom-guided treatment in improving lung, but this effect was lost after 3–7 years of usual care.40, 41 Repeated bronchial provocation testing is not feasible in clinical practice.

Measures of airway inflammation

Measures of airway inflammation (e.g. sputum eosinophil count, exhaled nitric oxide measurement) are not recommended in primary care to guide treatment decisions, but are increasingly used in specialist clinics.

Asthma treatment guided by sputum eosinophil count has been shown to reduce the frequency of flare-ups in adults with asthma, but there is insufficient evidence to ascertain its value for children.42

Exhaled nitric oxide measurement may be useful in guiding asthma management in some children. In children not taking inhaled corticosteroid, a high nitric oxide level probably predicts a good short-term response to inhaled corticosteroid treatment,43 but it does not distinguish between asthma and eosinophilic bronchitis and is often high in children with atopy. There is insufficient evidence to ascertain whether a low exhaled nitric oxide level predicts successful withdrawal from inhaled corticosteroids without asthma relapse,43 or safety of treating asthma without inhaled corticosteroids.

A Cochrane review44 found that exhaled nitric oxide-guided management was significantly better than other approaches to adjusting medicines for reducing the number of children with flare-ups and the number of children who needed oral corticosteroids, but did not reduce the frequency of flare-ups or the rate of flare-ups requiring hospitalisation, improve lung function or symptoms scores, or reduce inhaled corticosteroid doses. The authors concluded that it could not be recommended for all children but may be beneficial for a subset not yet defined.44

Towards personalised asthma care

Emerging understanding of asthma phenotypes and of genetic factors that predict therapeutic response to preventer options is leading to the possibility of personalised, genomics-based treatment for asthma in children.45 In the near future, individual tailored therapy is may replace the standardised step model based on population data.

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Classification of recent asthma symptom control in children

Ongoing review of asthma involves both assessing recent asthma symptom control and assessing risks for poor asthma outcomes such as flare-ups and adverse effects of medicines.

Recent asthma symptom control is assessed according to the frequency of asthma symptoms over the previous 4 weeks.

Table. Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen)

Good control Partial control Poor control

All of:

  • Daytime symptoms ≤2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • No limitation of activities
  • No symptoms§ during night or when wakes up
  • Need for SABA reliever# ≤2 days per week

Any of:

  • Daytime symptoms >2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • Any limitation of activities*
  • Any symptoms during night or when wakes up††
  • Need for SABA reliever# >2 days per week

Either of:

  • Daytime symptoms >2 days per week (lasting from minutes to hours or recurring, and partially or fully relieved by SABA reliever)
  • ≥3 features of partial control within the same week

SABA: short-acting beta2 agonist

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including doses taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

​* e.g. wheeze or breathlessness during exercise, vigorous play or laughing

†† e.g. waking with symptoms of wheezing or breathing problems

Notes:

Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes should also be assessed and taken into account in management.

Validated questionnaires can be used for assessing recent symptom control:
Test for Respiratory and Asthma Control in Kids (TRACK) for children < 5 years
Childhood Asthma Control Test (C-ACT) for children aged 4–11 years

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Table. Risk factors for life-threatening asthma flare-ups in children

Asthma-related factors

Poor asthma control

Admission to hospital in preceding 12 months

History of intubation for acute asthma

Over-use of short-acting beta2 agonist reliever

Abnormal spirometry findings

Reversible expiratory airflow limitation on spirometry despite treatment

Poor adherence to preventer

Incorrect inhaler technique for preventer

Poor adherence to asthma action plan

Exposure to clinically relevant allergens

Exposure to tobacco smoke

Other clinical factors

Allergies to foods, insects, medicines

Obesity

Family-related factors

Frequent failure to attend consultations/lack of follow-up after an acute flare-up

Significant parental psychological or socioeconomic problems

Parent/carer unequipped to manage asthma emergency

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References

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