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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
PubMed

Insights

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.
Abstract

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