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Long-term asthma treatment guided by airway hyperresponsiveness in children: a randomised controlled trial

¹ Dept of Paediatric Respiratory Medicine, Juliana Children’s Hospital, The Hague, ² Dept of Epidemiology and Biostatistics, Erasmus University Medical Centre, and ⁵ Dept of Paediatric Respiratory Medicine, Erasmus University Medical Centre/Sophia Children’s Hospital, Rotterdam, ³ Dept of Pulmonology, Academic Medical Centre, Amsterdam, and ⁴ Dept of Paediatric Respiratory Diseases, University Medical Centre Groningen, Groningen, The Netherlands. ⁶ Members are listed in the Acknowledgements section.

CORRESPONDENCE: J. C. de Jongste, Dept of Paediatric Respiratory Medicine, Erasmus Medical Centre/Sophia Children’s Hospital, P.O. Box 2060<@city>3000CB</city>, Rotterdam, The Netherlands.. Fax: 31 104636811. E-mail: j.c.dejongste{at}erasmusmc.nl

Keywords: Airway hyperresponsiveness, childhood asthma, inhaled corticosteroids, lung function in disease, salmeterol, symptom evaluation and management

Received: August 27, 2006
Accepted May 11, 2007

Management plans for childhood asthma show limited success in optimising asthma control. The aim of the present study was to assess whether a treatment strategy guided by airway hyperresponsiveness (AHR) increased the number of symptom-free days and improved lung function in asthmatic children, compared with a symptom-driven reference strategy.

In a multicentre, double-blind, parallel-group, randomised, 2-yr intervention trial, 210 children (aged 6–16 yrs) with moderate atopic asthma, selected on the basis of symptom scores and/or the presence of AHR, were studied. At 3-monthly visits, symptom scores, forced expiratory volume in one second (FEV₁) and methacholine challenge results were obtained, and medication (five levels of fluticasone with or without salmeterol) adjusted according to algorithms based on symptom score (reference strategy, n = 104) or AHR and symptom score (AHR strategy, n = 102).

After 2 yrs, no difference was found in the percentage of symptom-free days between treatment strategies. Pre-bronchodilator FEV₁ was higher in the AHR strategy (2.3% predicted). This was entirely explained by a gradual worsening of FEV₁ in a subgroup of 91 hyperresponsive children enrolled with low symptom scores (final difference between study arms was 6%).

Asthma treatment guided by airway hyperresponsiveness showed no benefits in terms of number of symptom-free days, but produced a better outcome in terms of pre-bronchodilator forced expiratory volume in one second in allergic asthmatic children, especially those characterised by low symptom scores despite airway hyperresponsiveness.