New research could help physicians tailor asthma therapy in children

From the February 2005 Journal of Allergy & Clinical Immunology

Researchers have identified specific asthma characteristics in children that could help determine the type of asthma treatment they will best respond to. These findings were published in the February 2005 Journal of Allergy & Clinical Immunology (JACI). The JACI is the peer-reviewed, scientific journal of the American Academy of Allergy, Asthma and Immunology (AAAAI). “Parents of children with asthma often ask: Is there a good way to determine what medication will work best in my child?” said Stanley J. Szefler, MD, FAAAAI. “These findings begin to address this question by taking a step toward enabling clinicians to better individualize asthma therapy.”

Dr. Szefler and colleagues from the National Heart, Lung, and Blood Institute’s (NHLBI’s) Childhood Asthma Research and Education (CARE) Network found specific differences in responses to the inhaled corticosteroid, fluticasone, and the leukotriene receptor antagonist, montelukast, in children with mild-to-moderate persistentasthma.

Inhaled corticosteroids are anti-inflammatory medications that go directly into the lungs, reducing inflammation in the airways. Leukotriene receptor antagonists treat asthma differently by blocking substances in the lungs called leukotrienes, which cause narrowing and swelling of the airways. While both medications are considered effective daily treatments for long-term care and prevention of exacerbations in patients of all ages with persistent asthma (those who have symptoms at least two days a week or two nights a month), the National Asthma Education and Prevention Program asthma treatment guidelines list inhaled corticosteroids as the preferred treatment, with leukotriene modifiers one of several alternative therapies.

“There is increasing evidence that children respond differently to the various treatment options for asthma,” noted James Kiley, PhD, director of the NHLBI Division of Lung Diseases. “If we can pinpoint in advance which children will do better with a certain type of therapy, we can improve their lives more quickly and save them the risk of trying medications that are less effective for them. This study adds important information for identifying which children are more likely to respond well to inhaled corticosteroids.”

Researchers administered fluticasone and montelukast separately for 8 weeks to 126 children (ages 6 to 17 years) with mild-to-moderate persistent asthma. During the course of the study, researchers evaluated the children’s lung function in response to each therapy to determine which medication produced the most favorable response.

The researchers reported on the percentage of children who improved lung function by 7.5% or greater based on a standard test. They found:

• 17% of the children reached the goal when taking both medications
• 23% of the children reached the goal when taking only the inhaled corticosteroid
• 5% of the children reached the goal when taking only the leukotriene receptor antagonist
• 55% of the children reached the goal when taking neither medication

Researchers noted that children whose asthma improved with inhaled corticosteroids had low pulmonary function and elevated markers of allergic inflammation at baseline. On the other hand, the children whose asthma was improved only by the leukotriene receptor antagonist were younger in age and had a shorter duration of the disease.

Based on these findings, researchers recommend that children with mild-to-moderate persistent asthma who have low lung function and/or elevated signs of allergic inflammation be treated daily with inhaled corticosteroids. Their findings also suggest that, in those children who have no elevated signs of allergic inflammation, a therapeutic trial of either medication can be conducted to determine which works best.