St. Louis, MO—The common practice is for clinicians to advise children with mild asthma to use a steroid inhaler daily, adding in a bronchodilator when symptoms occur.

A new study suggests a different protocol, however. The report in the Journal of Allergy and Clinical Immunology: In Practice found that as-needed use of both inhalers is just as effective for mild asthma as the traditional protocol.

The Washington University School of Medicine–led research focused on African American children, who are disproportionately affected by asthma.

“We were pleased to find that as-needed treatment based on symptoms can deliver similar asthma control with less medication,” said first author Kaharu Sumino, MD, an associate professor of medicine. “Patients in the group that used both inhalers as needed used about one-fourth the steroid dose of the group that inhaled a prescribed daily amount. We also were pleased to see that the patients and families felt that they had more ownership over their asthma management when practicing as-needed treatment.”

The rate of asthma among African American children is 13.4%, nearly double the 7.4% rate in white children, according to background information in the article.

The study was conducted by primary care doctors at multiple pediatric practices throughout the St. Louis area. The authors maintain that this suggests the new strategy is widely applicable in a real-world setting, adding that the approach reduced the amount of steroid medication used by the children each month by nearly 75%.

Included in the study were 206 African American children, ages 6 to 17 years, with mild asthma that was adequately controlled with asthma-controller steroid medication. Participants saw their own pediatricians at 12 primary care providers throughout St. Louis.

Patients were randomly assigned to one of two groups:
• Each participant in one group was advised to take a dose from an inhaler containing the steroid beclomethasone as needed when symptoms arose, along with the rescue bronchodilator albuterol. Patients were told that symptoms that might prompt the use of medication include shortness of breath, tightness in the chest, coughing, wheezing, and difficulty performing physical activities.
• Each participant in the second group was advised to take a specific inhaled dose of the steroid beclomethasone daily, regardless of symptoms, plus the rescue bronchodilator as needed in response to symptoms, as has been the standard recommendation for almost 30 years by the Global Initiative for Asthma guidelines.

At the end of the 1-year study, the researchers found no differences between groups in surveys of how well the patients’ asthma was controlled, as well as no differences in breathing tests that measure lung function. In addition, no differences were documented in the number of participants who sought extra medical care—such as office or emergency department visits—for asthma attacks.

The new protocol resulted in similar levels of asthma control with almost one-fourth of the exposure to inhaled steroids, the authors concluded, adding, “The mean difference in asthma control between groups was much smaller than the reported minimally important difference, indicating that there is little difference in real-life effectiveness” between symptom-based and provider-determined use of inhaled steroids to control mild asthma in children.

On average, children in the daily-use group used 1,961 mcg of steroids per month, while the symptom-based group used 526 mcg per month.

“Many families are concerned about the cost of this medication as well as the growth-related side effects, and stop taking their steroid medicine altogether. So, it’s nice to show that less medication—used as needed—is just as effective,” Sumino explained. “This as-needed steroid plus rescue albuterol strategy is now recommended in the Global Initiative for Asthma guidelines as one of the options for the treatment of mild asthma. Given the result of our study and others, primary care doctors may tell their patients with mild asthma that they have an alternative effective strategy other than taking the inhaled steroid every day, if they prefer not to do so.”

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