Sometimes, Less is More
Parents of children living with asthma know it’s important to keep their symptoms in check to prevent a dangerous exacerbation – sometimes called an asthma attack – in which inflamed bronchial passages make it hard to draw a breath. Powerful steroids called glucocorticoids can dampen the inflammation and improve lung function.
But more is not necessarily better. A new multi-center study (in which a University of New Mexico researcher participated) finds that quintupling the dose of an inhaled form of the medication to prevent worsening symptoms did not reduce the rate of asthma exacerbations.
Unexpectedly, the study, published online in The New England Journal of Medicine this week, also found that younger children on high doses of the medication had a lower growth rate than children on lower doses.
“The dose-response relationship that was observed in younger children . . . arouses the concern that more frequent or prolonged use of this strategy, if the use of inhaled glucocorticoids was its cause, could lead to greater adverse effects,” the authors wrote.
Asthma sufferers often follow a color-coded scheme to manage their symptoms, said Hengameh Raissy, PharmD, Research Professor in the UNM Department of Pediatrics, who was one of 38 scientists from around the country participating in the study through the National Heart, Lung, and Blood Institute’s (NHLBI) AsthmaNet research network.
"Green" means that asthma symptoms are well controlled, Raissy said. "Yellow" means that asthma symptoms are not well controlled and asthma treatment may need to change. "Red" means a severe worsening of symptoms that usually are treated with an oral corticosteroid, like prednisone.
“The purpose of this study was to find the best yellow zone action plan based on the child's asthma symptoms,” Raissy said. Inhaled glucorticoids are often administered in the yellow zone, and when they work, they prevent the symptoms from worsening to a full-blown exacerbation.
“Finding the best yellow zone strategy may prevent children from entering the red zone and having to take prednisone,” Raissy said. “The study also tried to determine which yellow zone strategy leads to the least total corticosteroid – oral and inhaled – use for children with asthma.”
The study, dubbed the Step Up Yellow Zone Inhaled Corticosteroids to Prevent Exacerbations (STICS) trial, enrolled 254 children, ages 5 to 11, at 17 sites around the U.S. Each participant had mild-to-moderate persistent asthma and had been treated at least once in the previous year with oral glucocorticoids for an asthma exacerbation.
The children were evenly divided, with one group receiving a low dose of an inhaled form of the drug whenever their symptoms started to worse and those in the other group receiving five times as much of the medication. “The rate of severe asthma exacerbations treated with systemic glucocorticoids did not differ significantly between groups,” the authors reported.
“These findings suggest that a short-term increase to high-dose inhaled steroids should not be routinely included in asthma treatment plans for children with mild-moderate asthma who are regularly using low-dose inhaled corticosteroids,” said study leader Daniel Jackson, MD, in a statement released by the NHLBI.
Jackson, an associate professor of pediatrics at the University of Wisconsin School of Medicine and Public Health, Madison, and an expert on childhood asthma, added, “Low-dose inhaled steroids remain the cornerstone of daily treatment in affected children.”