182 children who had uncontrolled asthma while receiving 100 µg of fluticasone bid were randomly assigned to receive each of three blinded step-up therapies for 16 weeks (4 months):- 250 µg of fluticasone twice daily (ICS step-up)
- 100 µg of fluticasone plus 50 µg of a long-acting beta-agonist twice daily (LABA step-up)
- 100 µg of fluticasone twice daily plus 5 or 10 mg of a leukotriene-receptor antagonist daily (LTRA step-up)
A differential response occurred in 161 of 165 patients who were evaluated.
The response to LABA step-up therapy was most likely to be the best response, as compared with responses to LTRA step-up and ICS step-up.
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.
The drugs with the best chance of success -- 45% -- were long-acting beta-agonists (LABAs), the study suggested. But safety concerns limit the use of these agents, the best known of which are Serevent and Foradil and the combination products Advair and Symbicort.
30% of the children did best either with a leukotriene-receptor antagonist (LTRA, brands include Accolate, Singulair, and Zyflo) or by doubling the dose of the child's current inhaled steroid medication.
References:
Step-up Therapy for Children with Uncontrolled Asthma Receiving Inhaled Corticosteroids. NEJM.
Choosing Asthma Step-up Care. NEJM.
How to Treat Kids' Hard-to-Control Asthma. WebMD.
Choosing Asthma Step-up Care. NEJM.
How to Treat Kids' Hard-to-Control Asthma. WebMD.
Off label use of inhaled corticosteroid/long-acting bronchodilator (LABA) in a 2-year-old child - AAAAI Ask the Expert.
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