Which ICS? There have been studies suggesting better control by fluticasone as compared to older Beclomethasone. One can start with Budesonide below 4 years of age without adding LABA. Fluticasone is newer ICS and can be used safely. Newer ciclesonide is also safer but long-term data is awaited.
What Dose? ICS are available in different strengths from 50 mcg to 800 mcg. Approximate divisions are made according to doses of Budesonide 100-800 mcg per day according to severity.
How should it be given? By strictly spacer and if baby is smaller than 4 years then use mask along with the spacer. Rotahaler for bigger babies only.
How long it should be given? It should be given for at least 3 months. Then step-down by 25% of dose every 3 monthly. Some times you may be able to stop after 6 months but keep monitoring. Baby may need prophylactic preventive therapy in winter season for 3 months. Spirometry (pulmonary function tests) may help you to tell when you should stop treatment.
I) Add-on therapy:
- LABA – Long acting beta 2 agonist-these can be added to ICS effectively. They reduce the doses of ICS & one can achieve better control. Ex:- Salmeterol & Fomoterol.
- LTRA – Leukoteriene receptor antagonist. Can be added to ICS for moderate and severe persistent asthma for 3 months. Can not be used alone. Ex:- Montelukast.
- Which add-on therapy is better?
Studies have shown that LABA are more better than LTRA.
- Can Montelukast be used for mild persistent asthma alone?
Not recommended. No replacement for ICS.
- Can LABA be used alone for bigger babies?
Not recommended. No replacement for ICS. LABA should be used in combination with ICS for all types of persistent asthma.
II) Other Drugs:
- Xanthines: Although Xanthines are efficacious their current use is restricted to add-on therapy with ICS.
- Anticholinergic drugs: Ipratropium for inhalation therapy.
- Sodium Cromoglycate & Ketotifen: Previously used frequently. Studies concluded that there is no difference between these drugs and placebo.
- Immunotherapy: Omalizumab-monoclonal antibody directed against IgE.
- Macrolides: These have both antimicrobial antinflammatory properties. Still evidence is required.
*A Profile:
62 patients are included in studies. 20 are below 1.5 years. No significant male and female differences. Association with allergic rhinitis is 60% below 1.5 years. Mild and moderate persistent group needed treatment for 3-6 months and coverage for winter season.
Severe persistent group needed treatment for 1-3 years and increase dose during winter season. Only 3 patients needed treatment for more than 3 years. In all of these patients ICS alone below 4 years group, ICS + LABA above 4 years group was used.
Montelukast was used only for 5 patients.
It shows the efficacy of ICS if used properly.
