Prescribing
in children
ICS are indicated as first-line therapy in children who require preventive medication, (ie, those with frequent episodic or mild persistent disease.)2, 22 ICS are also indicated in children with more moderate or severe asthma, or those who have not responded to non-steroidal medication after 2-4 weeks.22 The dose of ICS should be matched to the severity of symptoms. A dose-response study of budesonide found that exercise-induced asthma was controlled with an initial daily dose of 400 mcg daily, which should be adequate in most children.23 Referral to a respiratory physician is recommended if higher doses of ICS are required.
Once control has been in place for 2-3 months, the dose should be reduced in 25% decrements.2 Leukotriene receptor antagonists and LABAs also play a role in the management of childhood asthma; for further information, visit the NAC website for a copy of the information papers on these topics.
Safety issues in children
It is essential to ensure that ICS are used appropriately in children with asthma. Prescribers should be aware of the potential for dose-related systemic adverse effects, such as marked adrenal suppression. An Australian report recently documented cases of adrenal crisis (manifested by vomiting and hypoglycaemia) in three children taking high-dose ICS (500-1500 mcg fluticasone daily).6 In all three cases, significant dose reduction was possible without loss of asthma control, highlighting the importance of back titration to find the minimum effective dose.
If symptoms do not respond promptly to appropriate ICS doses, reconsider the diagnosis. Clinicians should also consider the natural history of childhood asthma: remission of asthma occurs spontaneously in approximately 85% of children, so regular review and reduction of the ICS to identify the minimum effective dose is important, to assess whether remission has occurred.
Management of childhood asthma exacerbations
Exacerbations of asthma in children are generally due to viral infections. Increasing the dose of ICS in these cases is ineffective, and oral steroids are recommended in those who require additional medication to manage an exacerbation. Loss of asthma control in children due to viral exacerbations does not necessitate an increase in the maintenance dose of ICS if there is good control of asthma between virally-induced episodes.
Role of the PharmacistPharmacists play a key role in asthma management, including monitoring and review of symptom control. It is essential for pharmacists, as primary health care providers, to:
The perfect opportunity for such interaction is provided when the customer has a repeat prescription dispensed or obtains an over-the-counter reliever. For example, when dispensing over-the-counter SABA, ask:
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