In a child with persistent asthma, initial
therapy options include low-dose ICS, montelukast or
cromones (Figure 2). If the initial choice is a cromone or montelukast, and adequate asthma control
is not achieved after a trial period of 4– 8 weeks,
cease the medication and initiate low-dose ICS.
As
with any asthma therapy, commence LTRAs for a trial
period of 4–8 weeks then reassess whether the
treatment is effective, well tolerated and
necessary.
Oral corticosteroids should not be
abruptly replaced by montelukast. In patients taking
montelukast, the dose of concomitant ICS may be
reduced gradually to the lowest dose then ceased.9Table 1 gives recommendations on commencing or
ceasing LTRAs depending on the child’s current
asthma severity and drug regimen. Oral montelukast
should not be relied on to manage acute asthma.9
Figure 2. Approach to preventive therapy in
children
Table 1. Recommendations
for starting and stopping LTRA treatment in
children with frequent intermittent or mild
persistent asthma
Current status
Action recommended
If poor response
Starting LTRA
Frequent
reliever use, no preventer therapy
Start LTRA
Trial for 4-8 weeks†
Start low-dose‡ICS
Sodium
cromoglycate or nedocromil sodium
Start LTRA
and cease cromone abruptly
Trial for
4-8 weeks†
Asthma well
controlled on lowest ICS dose for 3
months
Start LTRA
and cease ICS abruptly.
Trial for 4-8 weeks†
Recommence
ICS
Stopping LTRA
Good
control on LTRA for 3 months or end of
winter season of frequent intermittent
asthma
Cease LTRA
Recommence
LTRA or other preventer
† Trial period depends on pattern and
severity, e.g. 4 weeks may be sufficient
in mild persistent asthma. In frequent
intermittent asthma, a longer period may
be needed to evaluate the effect on
symptoms.
‡ Low-dose ICS: total daily dose of
beclomethasone dipropionate-HFA 100–200
mcg or fluticasone propionate 100–200
mcg or budesonide 200–400 mcg.1
