Asthma and lower airway disease
Decreased response to inhaled steroids in overweight and obese asthmatic children

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Background

The mechanisms and consequences of the observed association between obesity and childhood asthma are unclear.

Objectives

We sought to determine the effect of obesity on treatment responses to inhaled corticosteroids in asthmatic children.

Methods

We performed a post hoc analysis to evaluate the interaction between body mass index (BMI) and treatment with inhaled budesonide on lung function in the Childhood Asthma Management Program trial. Participants were then stratified into overweight/obese and nonoverweight groups, and their response to inhaled budesonide was analyzed longitudinally over the 4 years of the trial.

Results

There was a significant interaction between BMI and budesonide for prebronchodilator FEV1/forced vital capacity (FVC) ratio (P = .0007) and bronchodilator response (BDR; P = .049) and a nonsignificant trend for an interaction between BMI and budesonide on prebronchodilator FEV1 (P = .15). Nonoverweight children showed significant improvement with inhaled budesonide in lung function (FEV1, FEV1/FVC ratio, and BDR) during the early (years 1-2) and late (years 3-4) stages of the trial. Overweight/obese children had improved FEV1 and BDR during the early but not the late stage of the trial and showed no improvement in FEV1/FVC ratio. When comparing time points at which both groups showed a significant response, the degree of improvement among nonoverweight children was significantly greater than in overweight/obese children at most visits. Nonoverweight children had a 44% reduction in the risk of emergency department visits or hospitalizations throughout the trial (P = .001); there was no reduction in risk among overweight/obese children (P = .97).

Conclusions

Compared with children of normal weight, overweight/obese children in the Childhood Asthma Management Program showed a decreased response to inhaled budesonide on measures of lung function and emergency department visits/hospitalizations for asthma.

Section snippets

Study population

The Childhood Asthma Management Program (CAMP) study is a randomized clinical trial that enrolled 1,041 children with asthma between 1993 and 1995. A detailed description of the trial has been previously published.17 Inclusion criteria were age 5 to 12 years, a history of asthma for at least 6 months in the previous year, mild-to-moderate asthma severity, and airway responsiveness to 12.5 mg/mL or less of methacholine. Subjects were randomly assigned to one of 3 inhaled treatment arms (200 μg

Results

Baseline characteristics of the study population are presented in Table I. As expected from randomization, there were no differences in most subjects’ characteristics among treatment arms at baseline within each BMI group (overweight/obese vs nonoverweight). However, serum vitamin D levels were slightly higher in children receiving inhaled budesonide than in those receiving inhaled placebo or nedocromil regardless of BMI group. The mean age of the 1,041 participating children was 8.9 years,

Discussion

To our knowledge, this is the first report of modification of the effect of inhaled corticosteroids on pediatric asthma control by overweight/obesity status. Among children in a large multicenter clinical trial, nonoverweight children had more consistent and significant effects of inhaled budesonide on measures of lung function and asthma morbidity and severity than overweight/obese children.

FEV1 and FEV1/FVC ratio are widely used in clinical practice and constitute one of the components of the

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    The Childhood Asthma Management Program (CAMP) trial and CAMP Continuation Study were supported by contracts NO1-HR-16044, 16045, 16046, 16047, 16048, 16049, 16050, 16051, and 16052 with 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.

    Disclosure of potential conflict of interest: A. Fuhlbrigge is a consultant for Genentech, Novartis, and the Lovelace Respiratory Research Institute and serves on respiratory specialist advisory panels for Sunovion and Merck. The rest of the authors have declared that they have no conflict of interest.

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