Figures
- Fig. 1—
Management approach based on control for children >5 yrs of age, adolescents and adults. Alternative reliever treatments include inhaled anticholinergics, short-acting oral β2-agonists, some long-acting β2-agonists and short-acting theophylline. Regular dosing with short- and long-acting β2-agonist is not advised unless accompanied by regular use of an inhaled glucocorticosteroid (ICS). The available literature on treatment of asthma in children aged ≤5 yrs precludes treatment recommendations. The best-documented treatment to control asthma in this age group is ICS and, at step 2, a low-dose ICS is recommended as the initial controller treatment. Equivalent doses of ICSs, some of which may be given as a single daily dose, are provided in table 5⇓. ░: preferred controller options. #: receptor antagonist or synthesis inhibitors.
- Fig. 2—
Management of asthma exacerbations in the acute care setting. PEF: peak expiratory flow; FEV1: forced expiratory volume in one second; PCO2: carbon dioxide tension; PO2: oxygen tension. 1 mmHg = 0.133 kPa.
Tables
- Table 1—
Description of levels of evidence
Evidence category Sources of evidence Definition A RCTsRich body of data Evidence is from end-points of well-designed RCTs that provide a consistent pattern of findings in the population for which the recommendation is made. Evidence Category A requires substantial numbers of studies involving substantial numbers of participants. B RCTsLimited body of data Evidence is from end-points of intervention studies that include only a limited number of patients, post hoc or subgroup analysis of RCTs, or meta-analysis of RCTs. In general, Evidence Category B pertains when few randomised trials exist, they are small in size, they were undertaken in a population that differs from the target population of the recommendation, or the results are somewhat inconsistent. C Nonrandomised trialsObservational studies Evidence is from outcomes of uncontrolled or nonrandomised trials or from observational studies. D Panel consensus judgment This Evidence Category is used only in cases where the provision of some guidance was deemed valuable but the clinical literature addressing the subject was insufficient to justify placement in one of the other categories. The Panel Consensus is based on clinical experience or knowledge that does not meet the aforementioned criteria. RCT: randomised controlled trial.
- Table 2—
Classification of asthma severity by clinical features before treatment
Intermittent Symptoms less than once a week Brief exacerbations Nocturnal symptoms not more than twice a month FEV1 or PEF ≥80% pred PEF or FEV1 variability <20% Mild persistent Symptoms more than once a week but less than once a day Exacerbations may affect activity and sleep Nocturnal symptoms more than twice a month FEV1 or PEF ≥80% pred PEF or FEV1 variability <20–30% Moderate persistent Symptoms daily Exacerbations may affect activity and sleep Nocturnal symptoms more than once a week Daily use of inhaled short-acting β2-agonist FEV1 or PEF 60–80% pred PEF or FEV1 variability >30% Severe persistent Symptoms daily Frequent exacerbations Frequent nocturnal asthma symptoms Limitation of physical activities FEV1 or PEF ≤60% pred PEF or FEV1 variability >30% FEV1: forced expiratory volume in one second; PEF: peak expiratory flow; % pred: % predicted.
- Table 3—
Levels of asthma control
Characteristic Controlled (all of the following) Partly controlled (any measure present in any week) Uncontrolled Daytime symptoms None (twice or less per week) More than twice a week Three or more features of partly controlled asthma present in any week Limitations of activities None (twice or less per week) Any Three or more features of partly controlled asthma present in any week Nocturnal symptoms/awakening None Any Three or more features of partly controlled asthma present in any week Need for reliever/rescue treatment None (twice or less per week) More than twice a week Three or more features of partly controlled asthma present in any week Lung function (PEF or FEV1)# Normal <80% pred or personal best (if known) Three or more features of partly controlled asthma present in any week Exacerbations None One or more per year¶ One in any week+ PEF: peak expiratory flow; FEV1: forced expiratory volume in one second; % pred: % predicted. #: lung function is not a reliable test for children aged ≤5 yrs; ¶: any exacerbation should prompt review of maintenance treatment to ensure that it is adequate; +: by definition, an exacerbation in any week makes that an uncontrolled asthma week.
- Table 4—
Estimated equipotent daily doses of inhaled glucocorticosteroids for adults#
Drug Low daily dose μg Medium daily dose μg High daily dose μg¶ Beclomethasone dipropionate 200–500 >500–1000 >1000–2000 Budesonide+ 200–400 >400–800 >800–1600 Ciclesonide+ 80–160 >160–320 >320–1280 Flunisolide 500–1000 >1000–2000 >2000 Fluticasone propionate 100–250 >250–500 >500–1000 Mometasone furoate+ 200–400 >400–800 >800–1200 Triamcinolone acetonide 400–1000 >1000–2000 >2000 Notes. 1) The most important determinant of appropriate dosing is the clinician's judgment of the patient's response to therapy. The clinician must monitor the patient's response in terms of clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose of medication should be carefully titrated to the minimum dose required to maintain control, thus reducing the potential for adverse effects. 2) Designation of low, medium and high doses is provided from manufacturers' recommendations where possible. Clear demonstration of dose–response relationships is seldom provided or available. The principle is, therefore, to establish the minimum effective controlling dose in each patient, as higher doses may not be more effective and are likely to be associated with greater potential for adverse effects. 3) As CFC preparations are taken from the market, medication inserts for hydrofluoroalkane preparations should be carefully reviewed by the clinician for the equivalent correct dosage, as a low dose may be indicated. #: Comparisons based upon efficacy data. ¶: Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to consider alternative combinations of controllers. Maximum recommended doses are arbitrary but with prolonged use are associated with increased risk of systemic side-effects. +: Approved for once-daily dosing in milder patients.
- Table 5—
Estimated equipotent daily doses of inhaled glucocorticosteroids for children#
Drug Low daily dose μg Medium daily dose μg High daily dose μg¶ Beclomethasone dipropionate 100–200 >200–400 >400 Budesonide+ 100–200 >200–400 >400 Ciclesonide+ 80–160 >160–320 >320 Flunisolide 500–750 >750–1250 >1250 Fluticasone propionate 100–200 >200–500 >500 Mometasone furoate+ 100–200 >200–400 >400 Triamcinolone acetonide 400–800 >800–1200 >1200 Notes. 1) The most important determinant of appropriate dosing is the clinician's judgment of the patient's response to therapy. The clinician must monitor the patient's response in terms of clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose of medication should be carefully titrated to the minimum dose required to maintain control, thus reducing the potential for adverse effects. 2) Designation of low, medium and high doses is provided from manufacturers' recommendations where possible. Clear demonstration of dose–response relationships is seldom provided or available. The principle is, therefore, to establish the minimum effective controlling dose in each patient, as higher doses may not be more effective and are likely to be associated with greater potential for adverse effects. 3) As CFC preparations are taken from the market, medication inserts for hydrofluoroalkane preparations should be carefully reviewed by the clinician for the equivalent correct dosage. #: Comparisons based upon efficacy data. ¶: Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to consider alternative combinations of controllers. Maximum recommended doses are arbitrary but with prolonged use are associated with increased risk of systemic side-effects. +: Approved for once-daily dosing in mild patients.
- Table 6—
Summary of glucocorticosteroids and growth in children
Uncontrolled or severe asthma adversely affects growth and final adult height No long-term controlled studies have reported any statistically or clinically significant adverse effects on growth of 100–200 μg·day−1 of inhaled glucocorticosteroids Growth retardation may be seen with all inhaled glucocorticosteroids when a high dose is administered Growth retardation in both short- and medium-term studies is dose dependent Important differences seem to exist between the growth-retarding effects of various inhaled glucocorticosteroids and inhalers Different age groups seem to differ in their susceptibility to the growth-retarding effects of inhaled glucocorticosteroids; children aged 4–10 yrs are more susceptible than adolescents Glucocorticosteroid-induced changes in growth rate during the first year of treatment appear to be temporary Children with asthma treated with inhaled glucocorticosteroids attain normal adult height (predicted from family members) but at a later age - Table 7—
Summary of bones and glucocorticosteroids in children
No studies have reported any statistically significant increased risk of fractures in children taking inhaled glucocorticosteroids Oral or systemic glucocorticosteroid use increases the risk of fracture. The risk of fracture increases along with the number of treatments, with a 32% increase at four courses ever. Use of inhaled glucocorticosteroids reduces the need for systemic courses Controlled longitudinal studies of 2–5 yrs’ duration and several cross-sectional studies found no adverse effects of inhaled glucocorticosteroid treatment on bone mineral density No prospective studies have followed children on inhaled glucocorticosteroid treatment until peak bone mineral density has been reached
