Pearls of Wisdom: Daily ICS for Persistent Asthma, Right?

John is a 3-year-old boy with a history of asthma and recurrent wheezing, which is controlled by daily inhaled corticosteroid (ICS) use. At his latest checkup, John's mother expresses concern about the effect of daily ICS use on growth and asks whether it is possible for John to only use his inhaler during flare-ups. 

Do ICSs need to be taken daily by wheezing toddlers?

A. Yes, otherwise they are ineffectual.
B. Yes, because guidelines recommend them daily.
C. No, some information indicates comparable efficacy when administered only during flare-ups.
D. No, every other day administration has been shown to be equally effective.

What is the correct answer?
(Answer and discussion on next page)

Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).

Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.

Answer: No, some information indicates nearly comparable efficacy when administered only during flare-ups.

Current treatment algorithms recommend ICSs for children with persistent asthma, but do these drugs need to be taken every day?

The Research

The 2011 Maintenance and Intermittent Inhaled Corticosteroids in Wheezing Toddlers (MIST) trial followed 213 children (aged 12-53 months) who were randomly assigned to 2 groups. Children in the first group were given an ICS (budesonideevery night for 1 year, while children in the second group were given a placebo every night for 1 year and an ICS only during flare-ups.¹

MIST: Rx Arms

All participants in the study had to have had 4 or more wheezing episodes or experienced severe exacerbations requiring systemic steroids or a trip to the emergency department within the last year.

The primary outcomes of the study were the amount of ICS used and the number of asthma exacerbations reported.

Budesonide Daily vs As Needed

The Results

The researchers found that the frequency of exacerbations was essentially the same regardless of whether the children were taking ICSs daily or only when needed.

Furthermore, they found that children taking ICSs every day were more likely to experience growth delay (7.76 cm increase in height vs 8.01 cm increase in height) than children taking ICSs only when needed.

MIST: Outcomes

What’s The “Take-Home”?

Children who took ICSs only when needed used significantly less of the medication than those who took it every day. With little difference between efficacy between the 2 groups, and with the growth delay associated with frequent use, there appears to be little disadvantage with taking ICSs on an as-needed basis rather than daily.

Reference:
1. Zeiger RS, Mauger D, Bacharier LB, et al; CARE Network of the National Heart, Lung, and Blood Institute. Daily or intermittent budesonide in preschool children with recurrent wheezing. N Engl J Med. 2011;365(21):1990-2001.