What is the stepwise approach to pharmacologic therapy for pediatric asthma?

Updated: Jan 08, 2019
  • Author: Girish D Sharma, MD, FCCP, FAAP; Chief Editor: Kenan Haver, MD  more...
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Answer

A stepwise approach to pharmacologic therapy is recommended to gain and maintain control of asthma in both the impairment and risk domains. The type, amount, and scheduling of medication is dictated by asthma severity (for initiating therapy) and the level of asthma control (for adjusting therapy). Step-down therapy is essential to identify the minimum medication necessary to maintain control. See table below.

When children are well controlled, it is reasonable to try to reduce their therapy. Whether on relatively high-dose inhaled steroids, or a combination of steroid/long-acting beta2-agonist, it is best to try to continue to control them on a lower dose, or on less medication. Reducing inhaled steroids and/or eliminating the long-acting beta2-agonist could result in a deterioration in asthma control. When such steps are taken, it is critical to see those children frequently, monitoring their history, physical examination and spirometry. [48]

For pharmacotherapy, children with asthma are divided into 3 groups based on age: 0-4 y, 5-11 y, 12 y and older.

For all patients, quick-relief medications include rapid-acting beta2-agonists as needed for symptoms. The intensity of treatment depends on the severity of symptoms. If rapid-acting beta2-agonists are used more than 2 days a week for symptom relief (not including use of rapid-acting beta2-agonists for prevention of exercise induce symptoms), stepping up treatment may be considered. See the stepwise approach to asthma medications in Table 1, below.

Table 1. Stepwise Approach to Asthma Medications (Open Table in a new window)

Intermittent Asthma

Persistent Asthma: Daily Medication

Age

Step 1

Step 2

Step 3

Step 4

Step 5

Step 6

< 5 y

Rapid-acting beta2-agonist prn

Low-dose inhaled corticosteroid (ICS)

Medium-dose ICS

Medium-dose ICS plus either long-acting beta2-agonist (LABA) or montelukast

High-dose ICS plus either LABA or montelukast

High-dose ICS plus either LABA or montelukast; Oral systemic corticosteroid

Alternate regimen: cromolyn or montelukast

5-11 y

Rapid-acting beta2-agonist prn

Low-dose ICS

Either low-dose ICS plus either LABA, LTRA, or theophylline OR Medium-dose

Medium-dose ICS plus LABA

High-dose ICS plus LABA

High-dose ICS plus LABA plus oral systemic corticosteroid

Alternate regimen: cromolyn, leukotriene receptor antagonist (LTRA), or theophylline

Alternate regimen: medium-dose ICS plus either LTRA or theophylline

Alternate regimen: high-dose ICS plus either LABA or theophylline

Alternate regimen: high-dose ICS plus LRTA or theophylline plus systemic corticosteroid

12 y or older

Rapid-acting beta2-agonist as needed

Low-dose ICS

Low-dose ICS plus LABA OR Medium-dose ICS

Medium-dose ICS plus LABA

High-dose ICS plus LABA (and consider omalizumab for patients with allergies)

High-dose ICS plus either LABA plus oral corticosteroid (and consider omalizumab for patients with allergies)

Alternate regimen: cromolyn, LTRA, or theophylline

Alternate regimen: low-dose ICS plus either LTRA, theophylline, or zileuton

Alternate regimen: medium-dose ICS plus either LTRA, theophylline, or zileuton


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