Monday, October 5, 2015
New and future strategies to improve asthma control in children
Despite advances in care, asthma presents a significant burden on the pediatric population. The age of asthma diagnosis decreased from 4.7 years in 1993 to 2.6 year in 2000. Among children given a diagnosis before the age of 3 years, 35.6% to 45.2% continue to require care for the disease at age 6, and most of them already have lung function abnormalities. Early-onset asthma has long-lasting effects that continue into adolescence and adulthood, and severe childhood asthma is a risk factor for continued active disease as an adult. To date, no therapy has been able to prevent the development of pediatric asthma, and efforts continue to focus on achieving asthma control. Anderson and Szefler review the current and future approaches (J Allergy Clin Immunol 2015; 136(4): 848-859).
Adherence to controller therapies is essential to achieving disease control. Pediatric adherence specifically to inhaled corticosteroids (ICSs) has been reported to fall in the range of 20% to 33.9%, with only 4.7 to 5.5 prescription refills over 1 year. Most non-adherence among asthmatic patients is unintentional, resulting from forgetfulness or lack of parental supervision or health literacy. Electronic monitoring devices (EMDs) are an important development in addressing this problem. They record date, time, and location of inhaler use and provide real-time uploads to an Internet or smartphone application, in addition to providing reminders. Pediatric and adolescent studies using EMDs with reminders demonstrated a 40% to 54% increase in controller medications compared to those without them.
There are also many patients whose asthma remains uncontrolled, despite their closely following treatment regimens consisting of the most optimal current therapies. The need for new therapeutics is great, but there are complications in developing them for children. Traditionally, evidence for dosing, efficacy, and safety from adult studies influences pediatric drug development, but there are differences in pediatric respiratory function, immunology, and disease pathogenesis. Asthma medications are among the most prescribed off-label drugs in children. While second generation ICSs and LABAs appear to have altered the course of severe asthma over the past 20 years, ICS are associated with slowed growth and a reduction in adult height in children.
New inhaled therapies, such as single combination budesonide-formoterol inhaler maintenance and reliever therapy (SMART) and tiotropium provide promise for the future, as do a number of biologic drugs. As these therapies will be expensive, there is a need to identify biomarkers to indicate which patients they are most likely to benefit. The authors conclude the coming years will bring better options to control pediatric asthma, with the essential collaboration of patients, clinicians, and researchers.