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Severe asthma in children: therapeutic considerations
Louise Selby1,2, Sejal Saglani1,2
1Department of Respiratory Paediatrics, Royal Brompton Hospital.
Current Opinion in Allergy and Clinical Immunology
|February 6, 2019
Summary
Most children with problematic severe asthma (PSA) improve with adherence to inhaled corticosteroids. Only a small percentage with true severe therapy-resistant asthma (STRA) require additional treatments, necessitating further research into personalized therapies.
Area of Science:
- Pediatric Pulmonology
- Asthma Management
- Immunotherapy
Background:
- Problematic severe asthma (PSA) affects children despite maximal therapy.
- A multidisciplinary approach is crucial for identifying factors contributing to poor asthma control before escalating treatment.
- Objective adherence monitoring is key to distinguishing true severe therapy-resistant asthma (STRA) from non-adherence.
Purpose of the Study:
- To review the current understanding of problematic severe asthma (PSA) in children.
- To discuss the role of adherence monitoring and multidisciplinary assessment in managing pediatric asthma.
- To explore pathophysiological phenotyping and current add-on therapies for severe therapy-resistant asthma (STRA).
Main Methods:
- Review of adherence monitoring data, identifying a low prevalence of STRA (20-30%) among children with PSA.
- Examination of licensed biologic therapies (omalizumab, mepolizumab) for STRA in children aged 6 years and older.
- Analysis of available safety and efficacy data for biologics in pediatric populations.
Main Results:
- Electronic adherence monitoring reveals that most children with PSA have steroid-sensitive disease, not requiring additional therapies.
- Omalizumab has robust safety and efficacy data for reducing exacerbations in STRA, but predictive biomarkers are lacking.
- Mepolizumab has available pediatric safety data, but efficacy data is limited in younger children (6-11 years) and older adolescents (12+ years).
- A subset of children with STRA exhibit neutrophilia, though its clinical significance is unclear.
Conclusions:
- The majority of children with PSA benefit from adherence to inhaled corticosteroids.
- Add-on therapies are reserved for a minority with STRA, highlighting the need for precise phenotyping.
- Pragmatic clinical trials are essential for evaluating novel biologics and identifying optimal, individualized therapies for phenotyped children with STRA.
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