Original article
Asthma, lower airway diseases
Patterns of inhaled corticosteroid use and asthma control in the Childhood Asthma Management Program Continuation Study

https://doi.org/10.1016/j.anai.2009.11.004Get rights and content

Background

Daily controller medication use is recommended for children with persistent asthma to achieve asthma control.

Objective

To examine patterns of inhaled corticosteroid (ICS) use and asthma control in an observational study of children and adolescents with mild-to-moderate asthma (the Childhood Asthma Management Program Continuation Study).

Methods

We assessed patterns of ICS use during a 12-month period (consistent, intermittent, and none) and asthma control (well controlled vs poorly controlled). Multivariate logistic regression examined the association between pattern of ICS use and asthma control.

Results

Of 914 patients enrolled, 425 were recommended to continue receiving ICS therapy in the Childhood Asthma Management Program Continuation Study. Of these patients, 46% reported consistent ICS use and 20% reported no ICS use during year 1. By year 4, consistent ICS use decreased to 20%, whereas no ICS use increased to 57%; poorly controlled asthma was reported in 18% of encounters. In multivariate models controlling for age, sex, forced expiratory volume in 1 second, and asthma severity assessment, patients reporting consistent ICS use during a 12-month period were more likely to report poor asthma control (odds ratio, 1.6; 95% confidence interval, 1.2–2.1) compared with those reporting no ICS use.

Conclusions

In this observational study of children and adolescents with mild-to-moderate asthma, most did not report continued use of ICS. Patients recommended to continue receiving ICS therapy and reporting consistent ICS use were less likely to report well-controlled asthma even after controlling for markers of asthma severity. Although residual confounding by severity cannot be ruled out, many children and adolescents may not achieve well-controlled asthma despite consistent use of ICS.

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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    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.

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