NICE guidance - inhaled corticosteroids (steroids) for the treatment of chronic asthma in children under the age of 12 years

Summary points of the NICE guidance are outlined:

• for children under the age of 12 years with chronic asthma in whom treatment with an inhaled corticosteroid (ICS) is considered appropriate, the least costly product that is suitable for an individual child, within its marketing authorisation, is recommended
• for children under the age of 12 years with chronic asthma in whom treatment with an ICS and long-acting beta-2 agonist (LABA) is considered appropriate, the following apply.
  • the use of a combination device within its marketing authorisation is recommended as an option
  • the decision to use a combination device or the two agents in separate devices should be made on an individual basis, taking into consideration therapeutic need and the likelihood of treatment adherence
  • if a combination device is chosen then the least costly device that is suitable for the individual child is recommended

Notes:

• current British guidelines from the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) for the management of asthma recommend a stepwise approach to treatment in both adults and children
  • treatment is started at the step most appropriate to the initial severity of the asthma, with the aim of achieving early control of symptoms and optimising respiratory function. Control is maintained by stepping up treatment as necessary and stepping down when control is good
• mild intermittent asthma (step 1) is treated with inhaled short-acting beta-2 agonists (SABA)s, as required
  • introduction of regular preventer therapy with ICSs (step 2) should be considered when a child has had exacerbations of asthma in the previous 2 years, is using inhaled SABAs three times a week or more, is symptomatic three times a week or more, or is waking at night once a week because of asthma
    • in children who cannot take an ICS, a leukotriene receptor antagonist is recommended
• there is no precise ICS dose threshold for moving to step 3 (add-on therapy), in which a third drug is introduced:
  • in children aged 5-12 years, the guidelines recommend a trial of add-on therapy before increasing the daily dose of ICS above the equivalent of 400 micrograms of beclometasone dipropionate
  • first choice for add-on therapy in children older than 5 years is the addition of a LABA
  • in children aged 2-5 years, a leukotriene receptor antagonist should be considered
  • for children younger than 2 years, consideration should be given to referral to a respiratory paediatrician
• at step 4, further interventions may be considered if control remains inadequate
  • for children aged 5-12 years this may include increasing the daily dose of ICS to the equivalent of 800 micrograms of beclometasone dipropionate, or adding leukotriene receptor antagonists or theophyllines
  • for children younger than 5 years, step 4 is referral to a respiratory paediatrician (if not already from step 3)
  • at step 5 (for children aged 5-12 years only), continuous or frequent courses of oral corticosteroids are introduced. Before proceeding to this step, referral to a respiratory paediatrician should be considered
• majority of children with asthma are treated at steps 1, 2 or 3, with approximately 10% treated at either step 4 or 5

Reference:

• (1) NICE (November 2007).Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12 years