A new study challenges the use of daily dose of an inhaled steroid to keep asthma symptoms at bay in young children who have frequent bouts of wheezing. The researchers, who make up Childhood Asthma Research and Education (CARE) Network, an National Institutes of Health funded program, found that daily inhaled steroid treatment was no different in preventing wheezing episodes than treating children with higher doses of the drug at the first signs of a respiratory tract infection.
The researchers also found that daily treatment was comparable to use of the inhaled steroid intermittently at decreasing the severity of respiratory-tract illness, reducing the number of episode-free days or school absences, lowering the need for a rescue inhaler for acute asthma symptoms, improving quality of life, or reducing visits to urgent care or the emergency room.
The findings appear in The New England Journal of Medicine.
The MIST (Maintenance and Intermittent Inhaled Corticosteroids in Wheezing Toddlers) trial enrolled nearly 300 preschool-age children—between 12 months and 53 months old—who had recurrent wheezing and were at high risk for a worsening of asthma-like symptoms that could require treatment with oral steroids and/or a visit to urgent care or emergency room.
“We wanted to understand how to best treat young children who have repeated episodes of wheezing, most of whom appear symptomatic just when they have colds,” said Leonard B. Bacharier, MD, a Washington University pediatric asthma and allergy specialist at St. Louis Children’s Hospital. “Our goal was to start therapy at the first signs of a viral respiratory tract infection or cold to interrupt or slow the progression of symptoms. This trial was aimed to try to prevent wheezing severe enough that requires oral steroids and really gets in the way of children’s lives.”
A 2006 study by the same group of researchers, called the PEAK trial (Prevention of Early Asthma in Kids) found that daily treatment was effective in reducing episodes of wheezing requiring oral steroids. Physicians and parents, however, reported concerns about the drug’s effects on growth and are often reluctant to follow the treatment plan, so the researchers began to look for an alternative.
During the MIST trial, the children received either a dose of budesonide once a day through a nebulizer or an inactive placebo. At the first signs of a respiratory tract illness, those children who received the inactive placebo received a higher dose of budesonide twice a day, while those who received daily budesonide received a placebo twice daily and kept taking their regular budesonide. Neither the patients nor the physicians knew who received the active drug until the trial was over.
During the study, parents were asked to keep a daily diary of symptoms, such as coughing, wheezing, difficulty breathing, or other symptoms that interfered with normal activities, as well as a list of medications, visits to a health-care provider, or absences from daycare or school.
Because previous studies had shown that daily inhaled corticosteroid therapy was more effective than placebo, the researchers expected to see the same in the MIST trial. But that’s not what they found.
“The two groups were comparable in terms of episodes requiring oral steroids, symptom days, albuterol use and the time before oral steroids were needed,” said Bacharier. “All of the relevant indicators of disease activity were comparable.”
The results show there are a variety of treatments physicians can consider for children with frequent wheezing, added Bacharier.
“While daily therapy continues to be the recommended approach, in this group of children, whose disease is really evident only during respiratory tract illnesses with very few or no symptoms outside of that, instructing parents to treat them at the earliest signs of illness with a high dose of inhaled steroid diminishes the likelihood of an episode of illness requiring oral steroids comparable to giving them daily therapy,” said Bacharier.
Source: Washington University in St. Louis