Asthma Management Handbook

Guide to preventers: cromones

Overview

Preventers are used in maintenance treatment to reduce airway inflammation. They include cromones (cromoglycate and nedocromil sodium).

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More information

Cromones for children

0-5 years

Few clinical trials have assessed the use of inhaled sodium cromoglycate in preschool children and none have assessed nedocromil.1 Overall, sodium cromoglycate has not been shown to be effective in preschool children with multiple-trigger wheeze.1, 2

However, cromones are well tolerated and registered for use in infants. Therefore, a treatment trial can be considered before considering other preventers, particularly for children less than 2 years old.

6 years and over

Cromones are rarely prescribed in school-aged children.

Inhaled sodium cromoglycate might be effective in school-aged children, but interpretations of available evidence are inconsistent.3 Sodium cromoglycate is less effective than inhaled corticosteroid in achieving asthma control and improving lung function in children with persistent asthma.4

Nedocromil sodium appears to be have some benefit in children with persistent asthma, but its relative effectiveness compared with inhaled corticosteroids is not clear.5 Long-term (4–6 years) treatment with budesonide achieved better asthma control than long-term nedocromil in children with mild-to-moderate asthma aged 5–12 in a randomised placebo-controlled clinical trial.6

Practical issues

Cromones (sodium cromoglycate and nedocromil) may not be practical for some patients, because they require three–four times daily dosing until control is gained, and inhaler devices for cromones tend to block easily.3

Nedocromil can cause an unusual or unpleasant taste7 and is not tolerated by some children.

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Cromones for adults and adolescents

Sodium cromoglycate is less effective than inhaled corticosteroids in controlling asthma and improving lung function.4

Cromolyn sodium and nedocromil sodium taken before exercise can be used to manage exercise-induced bronchoconstriction, but they are only effective in approximately 50% of patients8 and are less effective than short-acting beta2 agonists.9

Cromones have a good safety profile and tolerance does not occur when either of these medicines is taken regularly.8 Maintenance of the CFC-free device is difficult for patients because the formulation is sticky and blocks the device unless it is washed and thoroughly dried every day. Therefore, patients need two mouthpieces to use alternately.

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Cromones for exercise-induced bronchoconstriction

Cromolyn sodium and nedocromil sodium administered by inhalation as single doses before exercise partially protect against exercise-induced bronchoconstriction in approximately half of patients.8

The onset of action is rapid. The duration of action is up to 2 hours.8

Recommended doses are as follows:10

  • nedocromil sodium 4–8 mg by inhalation, 5–10 minutes before exercise
  • sodium cromoglycate 10–20 mg by inhalation, 5–10 minutes before exercise.

Cromolyn sodium and nedocromil sodium are less effective than short-acting beta2 agonists in protecting against exercise-induced bronchoconstriction.9 However, they have a good safety profile and tolerance does not occur when either of these medicines is taken regularly.8

Sodium cromoglycate and nedocromil sodium inhalers must be washed daily to prevent blockage.

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References

  1. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from: http://erj.ersjournals.com/content/32/4/1096.full
  2. van der Wouden JC, Uijen JH, Bernsen RM, et al. Inhaled sodium cromoglycate for asthma in children. Cochrane Database Syst Rev. 2008; Issue 4: CD002173. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002173.pub2/full
  3. 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
  4. Guevara JP, Ducharme F M, Keren R, et al. Inhaled corticosteroids versus sodium cromoglycate in children and adults with asthma. Cochrane Database Syst Rev. 2006; Issue 2: CD003558. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003558.pub2/full
  5. Sridhar AV, McKean M. Nedocromil sodium for chronic asthma in children. Cochrane Database Syst Rev. 2006; Issue 3: CD004108. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004108.pub2/full
  6. The Childhood Asthma Management Program Research Group. Long-term effects of budesonide or nedocromil in children with asthma. The Childhood Asthma Management Program Research Group. N Engl J Med. 2000; 343: 1054-63. Available from: http://www.nejm.org/doi/full/10.1056/NEJM200010123431501#t=article
  7. Sanofi-Aventis Australia Pty Ltd. Product information: Tilade CFC-free (nedocromil sodium). Therapeutic Goods Administration, Canberra, 2008. Available from: https://www.ebs.tga.gov.au/
  8. Weiler JM, Anderson SD, Randolph C, et al. Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol. 2010; 105: S1-47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21167465
  9. Spooner CH, Spooner GR, Rowe BH. Mast-cell stabilising agents to prevent exercise-induced bronchoconstriction. Cochrane Database Syst Rev. 2003; 4: CD002307. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002307/full
  10. Stelmach I, Grzelewski T, Majak P, et al. Effect of different antiasthmatic treatments on exercise-induced bronchoconstriction in children with asthma. J Allergy Clin Immunol. 2008; 121: 383-389. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17980416