Faculty Opinions recommendation of Step-up therapy for children with uncontrolled asthma receiving inhaled corticosteroids.

Field: Medicine (Health Sciences)

BACKGROUND: For children who have uncontrolled asthma despite the use of low-dose inhaled corticosteroids (ICS), evidence to guide step-up therapy is lacking.METHODS: We randomly assigned 182 children (6 to 17 years of age), who had uncontrolled asthma while receiving 100 microg of fluticasone twice daily, to receive each of three blinded step-up therapies in random order for 16 weeks: 250 microg of fluticasone twice daily (ICS step-up), 100 microg of fluticasone plus 50 microg of a long-acting beta-agonist twice daily (LABA step-up), or 100 microg of fluticasone twice daily plus 5 or 10 mg of a leukotriene-receptor antagonist daily (LTRA step-up). We used a triple-crossover design and a composite of three outcomes (exacerbations, asthma-control days, and the forced expiratory volume in 1 second) to determine whether the frequency of a differential response to the step-up regimens was more than 25%.RESULTS: A differential response occurred in 161 of 165 patients who were evaluated (P< 0.001). The response to LABA step-up therapy was most likely to be the best response, as compared with responses to LTRA step-up (relative probability, 1.6; 95% confidence interval [CI], 1.1 to 2.3; P=0.004) and ICS step-up (relative probability, 1.7; 95% CI, 1.2 to 2.4; P=0.002). Higher scores on the Asthma Control Test before randomization (indicating better control at baseline) predicted a better response to LABA step-up (P=0.009). White race predicted a better response to LABA step-up, whereas black patients were least likely to have a best response to LTRA step-up (P=0.005).CONCLUSIONS: Nearly all the children had a differential response to each step-up therapy. LABA step-up was significantly more likely to provide the best response than either ICS or LTRA step-up. However, many children had a best response to ICS or LTRA step-up therapy, highlighting the need to regularly monitor and appropriately adjust each child's asthma therapy. (ClinicalTrials.gov number, NCT00395304.)2010 Massachusetts Medical Society PMID: 20197425 Funding information This work was supported by: NHLBI NIH HHS, United States Grant ID: U10 HL064307-04 NHLBI NIH HHS, United States Grant ID: U10 HL064313 NHLBI NIH HHS, United States Grant ID: U10 HL064307-05 NIAID NIH HHS, United States Grant ID: T32 AI007635-04 NHLBI NIH HHS, United States Grant ID: U10 HL064313-05 NCRR NIH HHS, United States Grant ID: M01 RR000051-44 NHLBI NIH HHS, United States Grant ID: U10 HL064295-07 NHLBI NIH HHS, United States Grant ID: U10 HL064305-10 NCRR NIH HHS, United States Grant ID: UL1 RR025780-01 NCRR NIH HHS, United States Grant ID: M01 RR000051-40 NHLBI NIH HHS, United States Grant ID: U10 HL064287-03 NHLBI NIH HHS, United States Grant ID: U10 HL064295-09 NHLBI NIH HHS, United States Grant ID: U10 HL064287-10 NHLBI NIH HHS, United States Grant ID: HL064295 NCRR NIH HHS, United States Grant ID: M01 RR000051-39 NCRR NIH HHS, United States Grant ID: UL1 RR025011-02 NCRR NIH HHS, United States Grant ID: M01 RR003186-16 NHLBI NIH HHS, United States Grant ID: U10 HL064305-02 NHLBI NIH HHS, United States Grant ID: U10 HL064305 NHLBI NIH HHS, United States Grant ID: U10 HL064295-05 NIAID NIH HHS, United States Grant ID: T32 AI007635-02 NHLBI NIH HHS, United States Grant ID: U10 HL064313-02 NCRR NIH HHS, United States Grant ID: M01 RR000036-40 NHLBI NIH HHS, United States Grant ID: U10 HL064305-04 NHLBI NIH HHS, United States Grant ID: U10 HL064288-04 NCRR NIH HHS, United States Grant ID: M01 RR003186-19 NHLBI NIH HHS, United States Grant ID: U10 HL064307-07 NHLBI NIH HHS, United States Grant ID: U10 HL064287-09 NCRR NIH HHS, United States Grant ID: UL1 RR025011 NHLBI NIH HHS, United States Grant ID: U10 HL064288-06 NHLBI NIH HHS, United States Grant ID: U10 HL064305-07 NCRR NIH HHS, United States Grant ID: M01 RR000051-45 NHLBI NIH HHS, United States Grant ID: U10 HL064295-03 NCRR NIH HHS, United States Grant ID: M01 RR000036-39 NHLBI NIH HHS, United States Grant ID: U10 HL064295-02 NCRR NIH HHS, United States Grant ID: M01 RR003186-15 NHLBI NIH HHS, United States Grant ID: U10 HL064307-02 NHLBI NIH HHS, United States Grant ID: U10 HL064287 NHLBI NIH HHS, United States Grant ID: U10 HL064288-07 NHLBI NIH HHS, United States Grant ID: U10 HL064295-04 NHLBI NIH HHS, United States Grant ID: U10 HL064313-03S1 NHLBI NIH HHS, United States Grant ID: U10 HL064288 NHLBI NIH HHS, United States Grant ID: U10 HL064287-01 NCRR NIH HHS, United States Grant ID: UL1 RR024992 NHLBI NIH HHS, United States Grant ID: U10 HL064295 NHLBI NIH HHS, United States Grant ID: HL064287 NIAID NIH HHS, United States Grant ID: T32 AI007635 NCRR NIH HHS, United States Grant ID: UL1 RR024992-03 NHLBI NIH HHS, United States Grant ID: U10 HL064288-02 NCRR NIH HHS, United States Grant ID: M01 RR000036 NHLBI NIH HHS, United States Grant ID: U10 HL064287-04 NHLBI NIH HHS, United States Grant ID: U10 HL064287-06 NHLBI NIH HHS, United States Grant ID: U10 HL064307 NIAID NIH HHS, United States Grant ID: T32 AI007635-01 NIAID NIH HHS, United States Grant ID: T32AI007635 NCRR NIH HHS, United States Grant ID: M01 RR000036-41 NHLBI NIH HHS, United States Grant ID: U10 HL064307-06 NHLBI NIH HHS, United States Grant ID: U10 HL064313-03 NHLBI NIH HHS, United States Grant ID: U10 HL064295-08 NCRR NIH HHS, United States Grant ID: UL1 RR025780 NHLBI NIH HHS, United States Grant ID: U10 HL064313-04 NHLBI NIH HHS, United States Grant ID: U10 HL064288-01S1 NHLBI NIH HHS, United States Grant ID: U10 HL064295-10 NHLBI NIH HHS, United States Grant ID: HL064288 NHLBI NIH HHS, United States Grant ID: U10 HL064288-05 NCRR NIH HHS, United States Grant ID: M01 RR000051-43 NCRR NIH HHS, United States Grant ID: M01 RR003186 NHLBI NIH HHS, United States Grant ID: U10 HL064313-07 NCRR NIH HHS, United States Grant ID: M01 RR000051-47 NHLBI NIH HHS, United States Grant ID: U10 HL064288-08 NCRR NIH HHS, United States Grant ID: UL1-RR025011 NCRR NIH HHS, United States Grant ID: UL1 RR024992-02 NIAID NIH HHS, United States Grant ID: T32 AI007635-03 NCRR NIH HHS, United States Grant ID: UL1 RR025011-01 NCRR NIH HHS, United States Grant ID: M01 RR000036-43 NHLBI NIH HHS, United States Grant ID: U10 HL064288-10 NCRR NIH HHS, United States Grant ID: UL1 RR025011-03 NHLBI NIH HHS, United States Grant ID: U10 HL064313-06 NHLBI NIH HHS, United States Grant ID: U10 HL064287-07 NHLBI NIH HHS, United States Grant ID: U10 HL064287-05 NCRR NIH HHS, United States Grant ID: M01-RR03186 NCRR NIH HHS, United States Grant ID: M01 RR000051-38 NCRR NIH HHS, United States Grant ID: M01 RR003186-17 NHLBI NIH HHS, United States Grant ID: U10 HL064313-01 NCRR NIH HHS, United States Grant ID: M01 RR000051-42 NHLBI NIH HHS, United States Grant ID: U10 HL064305-06 NHLBI NIH HHS, United States Grant ID: U10 HL064307-10 NHLBI NIH HHS, United States Grant ID: U10 HL064288-01 NCRR NIH HHS, United States Grant ID: M01 RR000051-46 NHLBI NIH HHS, United States Grant ID: U10 HL064288-09 NHLBI NIH HHS, United States Grant ID: U10 HL064295-06 NCRR NIH HHS, United States Grant ID: M01 RR000036-42 NHLBI NIH HHS, United States Grant ID: U10 HL064305-03 NCRR NIH HHS, United States Grant ID: UL1 RR024992-01 NHLBI NIH HHS, United States Grant ID: U10 HL064288-03 NCRR NIH HHS, United States Grant ID: M01 RR000051-41 NHLBI NIH HHS, United States Grant ID: U10 HL064307-09 NHLBI NIH HHS, United States Grant ID: U10 HL064305-05 NCRR NIH HHS, United States Grant ID: M01 RR003186-18 NHLBI NIH HHS, United States Grant ID: U10 HL064287-08 NHLBI NIH HHS, United States Grant ID: U10 HL064307-08 NHLBI NIH HHS, United States Grant ID: U10 HL064295-01 NCRR NIH HHS, United States Grant ID: M01 RR003186-14 NCATS NIH HHS, United States Grant ID: UL1 TR000448 NCRR NIH HHS, United States Grant ID: UL1-RR024992 NCRR NIH HHS, United States Grant ID: UL1-RR025780 NHLBI NIH HHS, United States Grant ID: U10 HL064307-03 NHLBI NIH HHS, United States Grant ID: U10 HL064305-08 NCRR NIH HHS, United States Grant ID: M01-RR00036 NCRR NIH HHS, United States Grant ID: M01-RR00051 NCRR NIH HHS, United States Grant ID: M01 RR000051 NHLBI NIH HHS, United States Grant ID: HL064313 NHLBI NIH HHS, United States Grant ID: HL064305 NHLBI NIH HHS, United States Grant ID: U10 HL064287-02 NHLBI NIH HHS, United States Grant ID: U10 HL064307-01 NCRR NIH HHS, United States Grant ID: M01 RR003186-20 NHLBI NIH HHS, United States Grant ID: HL064307 NCRR NIH HHS, United States Grant ID: UL1 RR025780-02 NHLBI NIH HHS, United States Grant ID: U10 HL064305-09 NHLBI NIH HHS, United States Grant ID: U10 HL064305-01 More Less keyboard_arrow_down