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Step-up and step-down treatments for optimal asthma control in children and adolescents
Jonathan A Bernstein1,2,3, Lyndon Mansfield4,5
1a University of Cincinnati, College of Medicine , Cincinnati , OH , USA.
Insights
Stepwise management of pediatric asthma is recommended, adjusting treatment up or down as needed. While inhaled corticosteroids are key, newer options like tiotropium exist, emphasizing individualized care for better outcomes.
Area of Science:
- Pediatric Pulmonology
- Asthma Management
- Pharmacotherapy
Background:
- Pediatric asthma requires tailored management considering growth and psychosocial development.
- Caregiver involvement is crucial for effective asthma control in children.
Purpose of the Study:
- To review therapeutic strategies for stepwise pediatric asthma management.
- To address unique needs of children, including treatment effects on development and caregiver roles.
Main Methods:
- Literature review including PubMed searches and analysis of guidelines.
- Inclusion of articles from personal files and relevant guidelines for asthma management in children.
Main Results:
- Stepwise asthma management (up or down) is recommended for children, mirroring adult guidelines.
- Inhaled corticosteroids are primary for persistent childhood asthma; newer options like tiotropium, anti-IgE, and anti-IL5 are available for specific steps.
- Stepping down treatment, though recommended, is underutilized but can reduce costs and adverse events while maintaining control.
Conclusions:
- Individualized treatment goals are essential for children with asthma.
- Step-up and step-down approaches maximize benefits and minimize adverse effects in pediatric asthma care.
- Enhanced patient education and monitoring are vital for optimal self-management and outcomes.
Objective:
To review therapeutic options for stepwise management of pediatric asthma in the context of this population's unique needs such as potential effects of asthma, treatments, or both on growth and psychosocial development, and caregiver involvement.
Data Sources And Study Selection:
We conducted PubMed searches to identify relevant articles then reviewed resultant articles, guidelines for asthma management in children, and articles from personal files.
Results:
Stepwise management of asthma, similar to adults, is recommended for children in current global and US guidelines. Treatment may be stepped up or stepped down temporarily or long-term based on response over time. Inhaled corticosteroids remain the recommended treatment for persistent childhood asthma and any potential small effects on growth are considered relatively minor compared with their benefit. Controller medication options for patients <18 years old are limited, especially for Global Initiative for Asthma Steps 2-5. The long-acting antimuscarinic antagonist tiotropium (Steps 4/5, patients aged ≥12 years) and in certain circumstances (Step 5), anti-immunoglobulin E (aged ≥6 years) and interleukin-5 antibodies (aged ≥12 years) are newer treatment options. Tiotropium is indicated in the United States and Europe for patients ≥6 years old. Stepping down treatment, which is recommended but infrequently practiced, can maintain symptom control and minimize adverse events while substantially reducing costs. Patient education and better monitoring remain important for self-management and optimum outcomes.
Conclusion:
A need exists to target individual treatment goals for children with asthma by using step-up and step-down approaches to maximize treatment benefits and minimize potential adverse effects.
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