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Therapy guidelines updated for childhood asthma

National Center on Health Statistics data state that in 1998, 11 million persons in the United States, including 3.8 million children, reported having an asthma attack. For the year 2000, the National Heart, Lung, and Blood Institute (NHLBI) estimated that the annual direct and indirect costs of asthma were $12.7 billion.

In response to the prevalence of asthma nationwide, and the fact that the number of Americans with the condition continues to increase, NHLBI initiated the National Asthma Education and Prevention Program (NAEPP) in 1989.

NAEPP convenes an 11-member expert panel as often as it deems necessary to update its guidelines for the diagnosis and management of asthma. The fields of allergy and immunology, family practice, internal medicine, pediatrics, pharmacology, public health, and pulmonary medicine are represented on the panel. Last month, the NAEPP expert panel issued an update of six selected topics in the asthma guidelines based on its review of scientific evidence.

Revisions have been made to the recommendations for treating infants and young children with mild to moderate persistent asthma. It is now recommended that long-term control therapy be initiated in infants and young children who within the past year have experienced more than three episodes of wheezing of more than one day's duration that affected their sleep and who have risk factors for the development of asthma—parental history of asthma or physician-diagnosed atopic dermatitis or two of the following: allergic rhinitis, wheezing apart from colds, or peripheral blood eosinophilia.

These therapeutic recommendations were made based on expert opinion or extrapolation of studies done in older children, because studies comparing medication in children younger than five years are not available.

Recommendations about the effects of long-term inhaled corticosteroid therapy on the vertical growth, bone mineral density, ocular health, and hypothalamic-pituitary-adrenal axis in children have been updated, but not changed, noted Charmaine Rochester, Pharm.D., drug information specialist and assistant professor of pharmacy, University of Mississippi Medical Center.

"Strong evidence from clinical trials that followed children for up to six years found that inhaled corticosteroids do not have a clinically significant or irreversible effect on these parameters," said Rochester. "Some data show that a child may have decreased growth velocity, which results in a height difference of approximately one centimeter during the first year of treatment. Over time, however, the child will catch up to his or her peers and will attain his or her true final height."

Therapeutic recommendations for the treatment of moderate persistent asthma have been revised, said Stanley Szefler, M.D., head, division of clinical pharmacology/ immunopharmacology, department of pediatrics, National Jewish Medical and Research Center, Denver. Low to moderate doses of inhaled corticosteroids are recommended for adults and children over five years of age, with long-acting inhaled beta₂ agonists added in the presence of inadequate control. For children under five years of age, he said, the two preferred options for treating moderate asthma are: long-acting inhaled beta₂ agonists and low doses of inhaled corticosteroids, or medium doses of inhaled corticosteroids as monotherapy.

These recommendations, too, were predicated on the opinion of the expert panel, given the lack of studies of adjuvant therapy combinations in children younger than five years. The guidelines specify that the preferred dosing methods are a nebulizer or a metered-dose inhaler with a mask.

These updates and revisions to the NAEPP asthma guidelines should influence how pharmacists counsel physicians and patients. "A pharmacist who notes that a patient is on very high doses of corticosteroids, but not a long-acting bronchodilator, might wish to recommend to the physician that the patient would be better served by combination therapy, thereby decreasing the risk of toxicity associated with high doses of inhaled corticosteroids," said William Kelly, Pharm.D., professor emeritus, pharmacy and pediatrics, University of New Mexico Health Sciences Center, Albequerque.

"Pharmacists who see a lot of children," Kelly continued, "can now counsel patients and parents that inhaled corticosteroids in low to medium doses are safe for use in pediatric patients, and they do not have to worry about potential long-term risks."

More information about NAEPP is available at www.nhlbi.nih.gov/about/naepp/index.htm . The Executive Summary of the NAEPP Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma-Update on Selected Topics 2002 is accessible at www.nhlbi.nih.gov/guidelines/asthma/index.htm .

Charlotte LoBuono

Charlotte LoBuono. Therapy guidelines updated for childhood asthma.

Drug Topics

2002;13:17.