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A new study from the University of Washington School of Medicine in St. Louis supports evidence that children with mild asthma can effectively manage the condition using their two inhalers – one steroid and the other bronchodilator – when symptoms occur. This is in contrast to the traditional method of using the steroid daily, regardless of symptoms, and the bronchodilator when symptoms occur. Where necessary, the use of both inhalers is as effective for mild asthma as the traditional protocol, according to investigators.
The steroid inhaler reduces inflammation, and the bronchodilator – also known as a lifesaving inhaler – relaxes the airway during an asthmatic attack to facilitate quick breathing.
The study focuses on African-American children who are disproportionately affected by asthma. The study appears in Journal of Allergy and Clinical Immunology: Practically,
"We are pleased to find that the necessary symptom-based treatment can provide similar asthma control with fewer medications," said first author Kaharu Sumino, associate professor of medicine. "Patients in the group who used both inhalers as needed use about a quarter of the steroid dose in the group inhaling the prescribed daily amount. We were also pleased to see that patients and families felt they had more ownership of asthma management when practicing the necessary treatment. "
In the US, about 6.2 million children under the age of 18 have asthma. Among white children, about 7.4 percent have asthma. Among African-American children, this figure is almost double, 13.4 percent. According to the Allergy and Asthma Foundation of America, asthma attacks account for 1.8 million emergency department visits a year, and African Americans are three times more likely than average to be hospitalized for asthma.
The study was conducted by primary care physicians at multiple pediatric practices in the St. Louis area, suggesting that the strategy is widely applicable in a primary care setting and is not simply effective when applied by researchers at an academic medical center.
Past clinical trials conducted in highly controlled settings at academic medical centers have suggested that the drug treatment approach works just as well as the traditional strategy for daily planned steroid rescue with an inhaler, if necessary. But how far this strategy can be translated into individual medical practices in the community is a question. Not only is this alternative, symptom-based, strategy effective when used by pediatric primary care physicians, the researchers found that the approach reduced the amount of steroid medication taken by children by nearly 75 percent per month.
The study included 206 African American children aged 6 to 17 years with mild asthma who were adequately controlled with steroid medication for asthma control. Participants saw their pediatricians at 12 primary care providers in St. Louis. Patients were randomly assigned to one of two groups. Each participant in one group was advised to take a dose of an inhaler containing steroid beclomethasone, if necessary, when symptoms appeared, along with the salvage bronchodilator albuterol. Symptoms that may trigger medication use include shortness of breath, chest tightness, coughing, wheezing, and difficulty exercising.
Each participant in the second group was advised to take a specific inhalation dose of steroid beclomethasone daily, regardless of symptoms, plus a rescue bronchodilator as needed in response to symptoms, as a standard recommendation for nearly 30 years of the Global Initiative for the Asthma Guidelines.
At the end of the one-year study, the researchers found no differences between study groups on how well patients were controlled for asthma, and differences in respiratory tests measuring lung function. There were no differences in the number of participants who sought additional medical care – such as office visits or emergency care – for asthma attacks.
As might be expected, the daily ingestion of beclomethasone, an inhaled corticosteroid, uses more drugs per month than those in the symptom-based group. On average, children in the daily use group used 1,961 micrograms per month, while the symptom-based group used 526 micrograms per month, reducing the amount of this medicine by almost three quarters. The reduced amount is desirable according to the researchers, as steroids have side effects that include stunted growth.
"Many families are concerned about the cost of this medicine, as well as the growth-related side effects, and are no longer taking their full steroid medicine. So it's good to show that fewer drugs – used when needed – are just as effective, "Sumino said. "This necessary steroid plus rescue albuterol strategy is now recommended in the Global Asthma Initiative guidelines as one of the options for treating mild asthma. Given the results of our study, and others, primary care physicians may tell their patients with mild asthma that they have an alternative effective strategy other than taking an inhaled steroid every day if they choose not to. "
Researchers also noted that children and carers in the need group reported that they believed they were actively managing their asthma care rather than relying passively on medical orders. A symptom-based strategy, in other words, gave them a sense of ownership of their asthma management, which is important for long-term disease control, according to Sumino and her colleagues.
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