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Assessment of corticosteroid response in pediatric patients with severe asthma by using a multidomain approach
Cara J Bossley1, Louise Fleming2, Nicola Ullmann2
1Respiratory Paediatrics, Royal Brompton Hospital and National Heart & Lung Institute, Imperial College London, London, United Kingdom; Respiratory Paediatrics, Kings College Hospital, London, United Kingdom.
Insights
Systemic corticosteroid response in pediatric severe therapy-resistant asthma (STRA) is complex. A multidomain approach shows complete steroid response is rare, highlighting heterogeneity in childhood asthma treatment.
Area of Science:
- Pediatric Pulmonology
- Asthma Research
- Clinical Pharmacology
Background:
- Defining systemic corticosteroid response in children with asthma lacks consensus.
- Pediatric severe therapy-resistant asthma (STRA) is a heterogeneous condition.
- Steroid response variability is expected in pediatric STRA patients.
Purpose of the Study:
- To assess a multidomain approach for determining steroid responsiveness in pediatric STRA.
- Incorporate symptoms, lung function, and inflammation markers to evaluate steroid response.
Main Methods:
- Eighty-two children with STRA received intramuscular triamcinolone acetonide.
- Assessed changes in symptoms, spirometry, fractional exhaled nitric oxide, and sputum eosinophils after 4 weeks.
- Utilized Asthma Control Test, FEV1, FeNO levels, and sputum eosinophil counts for evaluation.
Main Results:
- Individual domain response rates varied: 43% for symptoms, 54% for lung function, 52% for FeNO, and 54% for sputum eosinophils.
- No reliable predictors identified for specific response patterns.
- Complete responders (all domains) were rare (13%), nonresponders (0 domains) were 15%, and partial responders (≥1 domain) were 72%.
Conclusions:
- Multidomain evaluation confirms heterogeneity in childhood STRA and rarity of complete systemic steroid response.
- Individualized response patterns may guide selection of adjunctive therapies for personalized asthma management.
Background:
There is no agreed upon definition of systemic corticosteroid response in asthmatic children. Moreover, pediatric severe therapy-resistant asthma (STRA) is heterogeneous, and thus response to steroids is unlikely to be uniform in all patients.
Objective:
We sought to evaluate the utility of a multidomain approach incorporating symptoms, lung function, and inflammation to determine steroid responsiveness in pediatric patients with STRA.
Methods:
Eighty-two children (median age, 12 years) with STRA received a clinically indicated dose of intramuscular steroid. Changes in 4 separate domains were assessed 4 weeks after intramuscular triamcinolone acetonide: normalization of (1) symptoms (Asthma Control Test score, >19/25 or 50% increase), (2) spirometric results (FEV1 ≥80% of predicted value or ≥15% increase), (3) fraction of exhaled nitric oxide levels (<24 ppb), and (4) sputum eosinophil counts (<2.5%). Fifty-four of 82 children had complete data in all 4 domains.
Results:
Twenty-three (43%) of 54 children had a symptom response, 29 (54%) of 54 had a lung function response, 28 (52%) of 54 had a fraction of exhaled nitric oxide response, and 29 (54%) of 54 had a sputum eosinophil response. Although a similar proportion of children responded to systemic corticosteroids in each domain, there were no reliable predictors of a response pattern. Seven (13%) of 54 were complete responders (response in all domains), 8 (15%) of 54 were nonresponders (no response in any domain), and 39 (72%) of 54 were partial responders (response in ≥1 domain).
Conclusions:
A multidomain evaluation of systemic steroid responsiveness using pragmatic clinical assessments confirms childhood STRA is heterogeneous and that a complete response in symptoms and inflammatory and physiologic parameters is rare. Individual response patterns to systemic steroids might be useful in guiding the choice of add-on therapies in each child as a step toward achieving personalized medicine.
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