WHAT ARE THE CURRENT RECOMMENDATIONS FOR INITIAL CONTROLLER OR STEP-UP THERAPY?
Failure of over-the-counter medications to relieve a child's recurring respiratory symptoms is often the impetus for a visit to the pediatrician's office.7 Before initiating therapy, it is important for the HCP to determine what medications the child is currently taking and to establish the step of therapy the child is on, based on the 6-step treatment chart of the guidelines (Figure 3). It is also important to assess the need for these medications and whether continued treatment would be beneficial. The child already may be using an inhaled SABA as needed for quick relief of symptoms.6 The HCP should determine the frequency of inhaled SABA use to assess the need to step up therapy.
While the original API was developed to assess the likelihood that a child would experience persistent asthma, a modified API (mAPI) was used as an inclusion criterion in the Prevention of Early Asthma in Kids (PEAK) study to examine whether long-term ICS treatment would prevent disease progression in 285 children aged 2 to 3 years at high risk for persistent asthma.22
The original API was modified because allergic rhinitis is difficult to diagnose in young children and previously conducted studies have shown that early allergic sensitization to milk or eggs are predictors for developing persistent asthma. 22-24 Differences between the mAPI and the original API are described in Table 3.25 A positive mAPI requires the child to have at least 1 of 3 major risk factors or 2 of 3 minor risk factors. The PEAK study showed that children with the phenotype of a positive mAPI who received fluticasone propionate 88 µg twice daily had a significantly greater proportion of episode-free days (P = .006) and reduction in exacerbations requiring systemic corticosteroids (P < .001) compared with children who received placebo over the 2-year treatment period.26 The children were followed for 1 year after treatment was discontinued. Findings from the treatment-free year did not support a disease-altering effect after ICS discontinuation.
Nevertheless, the outcome of the PEAK trial led to the guideline recommendation that a long-term daily controller (ICS) be initiated for reducing risk and impairment in children younger than 5 years who have had 4 or more episodes of wheezing in the past year that lasted more than 1 day and affected sleep and who have risk factors for developing persistent asthma based on the mAPI.6,26 Many children have intermittent episodes of viral-induced wheezing, and the PEAK trial helps define which of those children with recurrent episodes will benefit from maintenance therapy. A daily long-term controller also should be considered for children with impairment (eg, persistent symptoms) or risk as outlined in Table 4.
Moreover, the guidelines recommend a stepwise treatment approach to maintain long-term asthma control (Figure 3).6 Daily controller therapy is recommended for persistent disease. An ICS is the preferred step 2 controller. A step up in therapy is warranted if asthma control is inadequate and a step down in therapy is recommended to achieve control with the minimal necessary amount of medication. A step down in therapy, with an ICS dose reduction of 25% to 50%, should be considered whenever the child's asthma has been well controlled for 3 or more months.