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Advanced Asthma Topics: Inhaled Corticosteroids

Solomon Behar, MD and Andi Marmor, MD
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Indications for starting an inhaled corticosteroid on a child with asthma include symptoms more than 2 times per week, more than 2 nighttime awakenings in a month for asthma, or more than 2 steroid courses in the year for asthma.  The National Heart, Lung, and Blood Institute has an online table available to assist providers with choosing the appropriate agent.

Pearls:

  • Any child with persistent asthma should be on a daily inhaled corticosteroid.

  • An initiation of an inhaled corticosteroid may be considered for a child who has one episode of severe status asthmaticus requiring hospitalization; regardless of weekly symptoms.

  • The National Heart, Lung, and Blood Institute (NHLBI) has guidelines on how to start, manage and discontinue inhaled corticosteroids.

 

  • When should a child be started on an inhaled corticosteroid (ICS)?  In short, a child who is having more than intermittent asthma (therefore, persistent asthma) should be on a daily  ICS.  To distinguish when a controller should be started, remember the rule of 2’s.  The rule of 2s refers to the following questions:

    • Does the child have more than 2 symptoms of asthma during the day each week?

      • And/or does the child use a short acting beta-agonist more than 2 times per week?

    • Does the child have more than 2 episodes of nighttime wakings per month?

    • Does the child have 2 or more hospitalizations/urgent care visits per month in which oral corticosteroids were prescribed?

      • This bullet points also refers to children who may not have daily or nightly symptoms, but when they get ill, they get very ill and need corticosteroids.  This is termed “episodic asthma.”  

If the answer is yes to any of the above questions, a controller should be started.  ICS should not be used as an abortive agent in status asthmaticus.  Status asthmaticus, as covered in previous episodes, should be treated with systemic therapies to include coverage for beta receptors.

  • What about a child who presents only one time for an asthma exacerbation, but is extremely ill during presentation/hospitalization?  While the literature is not conclusive, this may be considered a separate indication for initiating a ICS.  The reason is that such a severe exacerbation results in a severe amount of inflammation.  Therefore, some groups start these patients on 3 months of moderate dose ICS and reassess whether this can be stopped and/or stepped-down.

  • How do you decide on the dose of ICS?  The National Heart, Lung, and Blood Institute (NHLBI)  has guidelines for starting low, medium or high doses ICS which are based on the severity of the symptoms, the age of the child and the specific steroid you are starting.

    • Remember that based on the child’s age/weight, the low, medium and high doses will differ.

  • How do you decide which ICS to start?  The short answer is whichever ICS is more easily accessible for the patient.  There may be subtle differences in the ICS, specifically as related to long term growth.  Several large meta analyses have looked at the growth impact of ICS in children.  Some show that the specific steroid molecules matter; for example, these studies suggest that fluticasone may be a bit better than budesonide, which tends to be a it safer than beclomethasone.

    • Not yet on the market in the US, another ICS ciclesonide is a steroid that does not have systemic absorption and preliminary data shows it is as effective as other ICS without potential systemic side effects.

Loke YK.  Impact of Inhaled Corticosteroids on Growth in Children with Asthma:  Systematic Review and Meta-Analysis.  PLoS One. 2015 Jul 20;10(7):e0133428. PMID 26191797

  • What are the growth impacts of ICS?  This is an important side effect to discuss.  When ICS are at moderate or high doses and used for a year or more, the evidence shows that there is an impact on growth velocity - greatest in that first year of use and greater in younger children.  The impact on growth velocity decreases after the first year; but does not correct itself.  The difference ends up being about a centimeter or less in final adult height.  Again, there is some variability in terms of the steroid and dose used with the differences being that higher doses result in greater height differences.   This, of course, is balanced with the side effects of uncontrolled asthma and this should be discussed with the family.

  • Are there other side effects of ICS?  The only other side effect shown in large trials of high doses of ICS over long periods of time is a slight increase in cataracts.

    • The family may have other concerns about ICS, such as “roid rage”, testicular atrophy, gynecomastia, for example, and listening to families and explaining that these are not side effects of ICS may be important.  Parents may comment on changes in personality and/or difficult sleeping; these have not been substantiated side effects.

      • It may also be beneficial to discuss the differences between oral and ICS.  Specifically, that starting an ICS is to decrease the need for oral corticosteroids; which can have their own side effects.

  • What oral hygiene practices should be done after ICS use?  Rinsing the mouth with water or brushing teeth after use of ICS is important to prevent complications, such as oral thrush.

Editor’s note:  In addition, ICS can reduce the salivary flow which decreases the pH of the mouth, making the environment more susceptible to dental caries.,  Therefore, mouth washing should be completed immediately after ICS use.  The amount of ICS removed from the mouth is associated with the time lag between inhalation and mouth washing.

  • How do you decide how long and when to modify ICS use?  The NHLBI has guidelines for this too.  Ultimately, the goal is to have the patient on the lowest dose that achieves control.  The decision on how well controlled the patient is also uses the rule of 2s.  This control should be assessed every 3 months.  If a child has been well controlled on a dose for 3 months, the medication should be stepped-down.  When a child is down to a low dose ICS, one must weigh the risks/benefits of taking them off completely vs. keeping on the low dose (which is safe and effective long term).  

  • When can you stop the use of a ICS?  There are many things to consider.  If a patient has been well controlled on a low-dose ICS for a long period of time, it may be reasonable to stop the ICS all together.  Asthma triggers should be considered.  For example, stopping a child on an ICS at the beginning of winter, if weather change is a trigger, is not advised.  There is not good evidence for a “steroid holiday”, in terms of side effects, and if anything, these holidays actually increase the likelihood of an exacerbation.

    • The subset of patients with “episodic” asthma, as noted above, may benefit from being on a moderate or high dose ICS for a few weeks around an illness and this may happen a couple times per year.  These children have the symptoms of severe asthma only when they are ill; and therefore, it is hard to justify the use of daily ICS.  This practice should not be done for children who have more than a few episodes a year.  There is no evidence to support “stepping up” the dose of ICS when sick.

  • When and how should a long-acting beta-agonist (LABA) medication be used?  These medications should always be used in combination with an ICS.  For patients with moderate to severe persistent asthma, the studies in adults and some in kids, show better control with an ICS/LABA.  Therefore, for a child who is still having exacerbations on high dose ICS, addition of a LABA is reasonable.  The safety of these medications has been debated . In 2005, the FDA  placed a black box warning on some LABA; this remains in effect today.

    • Interestingly, formoterol is a LABA with a rapid onset of action.  Salmeterol is a longer acting agent.  Some studies have looked at the ICS/LABA combination for rescue medication in addition to maintenance.  The concern here is that there may take a very large amount of LABA in a day; and the maximum amount tolerated is not known.  Another concern is that the child may saturate his/her beta-agonist receptors and this could potentially make the child less sensitive to short acting beta-agonists.

    • LABAs are not approved for children less than 5 years old.  However, the guidelines state that if a child less than 5 has severe asthma that is not controlled on a high dose ICS, than a combination ICS/LABA should be considered.

  • How do you choose between stepping up a moderate dose ICS or adding a LABA?  There is not a clear answer for this.  Often if depends on the symptoms of the patient.  If a patient is symptomatic on daily medium dose ICS (and the patient is taking the medication correctly), it is reasonable to trial a combination ICS/LABA for three months and reassess.  If the child has had a good response, continuing with the regimen makes sense.  If they do not respond well, stepping up to a high dose ICS makes sense.

    • As stated, checking that patient is taking the medication correctly is of utmost importance.

  • To get back to the basics, how is asthma diagnosed?  Remember, asthma is a clinical diagnosis.  It is based on evidence of airway obstruction that is recurrent, persistent and reversible.  Saying to a family “your child has asthma” as opposed to saying “your child has reactive airways disease”, can be very powerful as it is one of the most common chronic conditions in childhood and one we know a great deal about.  Children can outgrow asthma, but this does not mean they did not have asthma.

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