Original articleAsthma, lower airway diseasesPatterns of inhaled corticosteroid use and asthma control in the Childhood Asthma Management Program Continuation Study
Introduction
Inhaled corticosteroids (ICSs) are recommended as first-line controller therapy for children and adolescents with persistent asthma.1 Consistent ICS use has been shown to improve asthma symptoms and lessen the frequency of asthma-related emergency department visits and hospitalizations.2 In contrast, underuse of ICSs has been associated with worse asthma outcomes.3 Intermittent use of ICSs and other asthma controller medications by patients is common, often because of patient or caregiver nonadherence to physician recommendations. However, in some situations, health care providers may be recommending intermittent controller medication use, particularly in children with milder disease or in children who have seasonally variable asthma.4 Indeed, the recent revisions of the National Heart, Lung, and Blood Institute asthma guidelines state that daily treatment only during specific periods of risk may be considered for some children.1
Whether intermittent asthma controller medication use leads to differential health outcomes compared with consistent use is unclear. A randomized trial5 of intermittent ICS use in adults with mild-to-persistent asthma showed that peak expiratory flow can be maintained successfully with intermittent symptom-based courses of ICS, yet other outcomes (eg, symptom days) are not well controlled. A similar study in children has not yet been completed. In young children with recurrent wheeze, one study6 of intermittent ICS therapy showed no effect on disease progression and no short-term benefit during episodes of wheezing.
Asthma treatment guidelines also recommend the systematic monitoring of asthma control in children to guide appropriate asthma therapy.7 Asthma control, which reflects the current symptom status of a child with asthma regardless of underlying disease severity, can be evaluated via several validated questionnaires, including the Asthma Control Test, the Asthma Therapy Evaluation Questionnaire, and the Asthma Control Questionnaire.8, 9, 10, 11 Multiple studies8, 12, 13, 14, 15 have shown that poor asthma control is associated with increased asthma-related hospitalizations and health care use. However, the relationship between patterns of asthma controller medication use, particularly intermittent controller medication use, and asthma control in children remains unclear.
We examined asthma controller medication use patterns within a cohort of children and adolescents with mild-to-moderate asthma who were enrolled in the Childhood Asthma Management Program Continuation Study (CAMPCS), an observational follow-up study to the original CAMP trial. We sought to determine the frequency of different patterns of asthma controller medication use and asthma control over time. We hypothesized that the pattern of asthma controller medication use, particularly consistent use, would be associated with improved patient-reported asthma control over time.
Section snippets
Periods of Study
CAMP was a 5-year, randomized, placebo-controlled trial of the safety and efficacy of 2 inhaled anti-inflammatory therapies for children with mild-to-moderate asthma. Characteristics of the patients, results of the trial, and treatment effects have been published previously.2, 16 At the completion of the clinical trial, participants were invited to enroll in CAMPCS, a 4.5-year, observational, follow-up study (1999–2004) to determine the effects of long-term treatment early in childhood on
Results
During the CAMPCS transition encounter, 425 (46.5%) of the 914 children and adolescents received a recommendation to continue ICS therapy for asthma treatment. Children who received a recommendation to use ICSs were more likely to be rated with moderate-to-severe asthma; were more likely to have a lower baseline FEV1, a lower FEV1/FVC ratio, and a higher mean serum IgE level; and exhibited more airway responsiveness (mean ln PC20, 0.7 vs 1.6) (Table 1). Also, more boys (65% vs 43%) received an
Discussion
Our analysis has characterized asthma controller medication use over time among children and adolescents with asthma enrolled in CAMPCS. We found that most participants reported well-controlled asthma symptoms and that no asthma controller medication was used during a 4-year observational period. Inhaled corticosteroid use continued to decrease during the study period and was not countered by a significant increased use of alternate asthma controller medications, such as LTRA. Among a subgroup
Acknowledgments
We thank Kelan Tantisira, MD, for his critical review of and input in the manuscript.
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Cited by (0)
Disclosures: Dr Fuhlbrigge has served as a consultant to GlaxoSmithKline, Merck, Novartis, and Sepracor (for epidemiologic studies); has received unrestricted research support from GlaxoSmithKline, Merck, and Boehringer Ingelheim; has served on an advisory board and been a member of a speakers bureau for GlaxoSmithKline and Merck; and has served as a member of the DSMB for an industry-sponsored clinical trial (Sepracor).
Funding Sources: This study was supported by an unrestricted research grant from Merck Inc. CAMP is supported by contracts NO1-HR-16044, NO1-HR-16045, NO1-HR-16046, NO1-HR-16047, NO1-HR-16048, NO1-HR-16049, NO1-HR-16050, NO1-HR-16051, and NO1-HR-16052 from the National Heart, Lung, and Blood Institute and General Clinical, Research Center grants M01RR00051, M01RR0099718–24, M01RR02719–14, and RR00036 from the National Center for Research Resources.