Table 4.
Recent Evidence for Emerging Trends in the Treatment of Asthma
| PRACTICE CONSIDERATION | EVIDENCE | RECOMMENDATION | |||
|---|---|---|---|---|---|
| POPULATION, No. | DESIGN | FINDINGS (LIMITATIONS) | |||
| School-based asthma therapy | |||||
| Halterman et al (2011) (82) | Children aged 3–10 y with asthma and Medicaid insurance (n = 530) | Prospective RCT comparing home versus school administration of ICS | School administration of ICS effectively improves adherence (performed in conjunction with dose adjustment as needed and tobacco smoke reduction program) (single site) | Recommend partnership with local school to see whether school-based asthma therapy is a feasible alternative to home-based therapy, especially for those patients with poor adherence. Consider direct delivery of medications to the school. | |
| Fall montelukast | |||||
| Johnston et al (2007) (83) | Children aged 2–14 y with asthma (n = 194) | RCT, double-blind, placebo-controlled trial comparing a group started on age-appropriate nightly dose of montelukast from September 1 for 45 d | 53% Decrease in “worse asthma symptoms” and 78% reduction in unscheduled asthma visits; boys 2–5 y and girls 10–14 y with most benefit (no minimum asthma severity for inclusion; pragmatic trial with poor adherence to ICS in study population) | Mixed results; could consider Fall montelukast in a persistent asthma population with poor ICS adherence (especially males aged 2–5 y and females aged 10–14 y) | |
| Weiss et al (2010) (84) | Children aged 6–14 y with asthma (n = 1162) | RCT, multicenter, double blind, placebo controlled, comparing 5-mg montelukast night before day 1 of school for 8 wk; evaluated percent days with worse asthma | No difference between placebo and montelukast groups (no minimum asthma severity for inclusion) | ||
| Preseasonal treatment with omalizumab | |||||
| Teach et al (2015) (85) | Inner-city asthmatic children aged 6–17 y with ≥1 recent exacerbations (n = 727) | 3-arm RCT, double blind, double placebo controlled, multicenter | Compared to placebo, omalizumab had a significantly lower rate of fall exacerbations, and omalizumab boosted interferon levels with a decrease in rhinovirus infection in the omalizumab group | Consider the addition of omalizumab to guidelines-based therapy for inner city children, aged 6-17 y, before the fall season, especially if they have a recent history of exacerbation | |
| Intermittent, extreme high-dose ICS dose for acute asthma | |||||
| Jackson et al (2018) (86) | Children aged 5–11 y with mild to moderate persistent asthma, with 1 course of systemic corticosteroids in previous year (n = 254) | Double-blind RCT comparing low-dose ICS with quintupled-dose ICS for 7 d at early signs of loss of asthma control | No difference between the groups in degree of asthma control | Good evidence to recommend against intermittent escalation in ICS for yellow zone management in children; however, seasonal increase may be supported in an urban setting (87)(88) | |
| McKeever et al (2018) (89) | ≥16 y on any dose of ICS with ≥1 exacerbation in previous 12 mo requiring systemic corticosteroids (n = 1,922) | Pragmatic, randomized, unblinded trial comparing self-increase in ICS to 4 times the dose with those that did not increase baseline ICS dose for yellow zone management × 14 d or peak flow normal | Fewer severe exacerbations in high-dose ICS group (no children in low-dose ICS group; subject to bias and found only 19% reduction in increased ICS group) (87)(88) | * This contradicts current GINA recommendations. (60) | |
| Decision support for guideline-based care | |||||
| Bell et al (2010) (17) | Urban primary care clinics (n = 12) | Cluster RCT trial of clinical decision support in the electronic health record | Improved primary care provider compliance with NAEPP guideline–based care (17) | Strong recommendation to consider implementation if feasible | |
| Oral prednisolone in preschoolers with wheeze | |||||
| Panickar et al (2009) (90) | Children aged 10–24 mo hospitalized for viral-induced wheeze (n = 700) | RCT, double-blind, placebo-controlled, 5-d course of oral prednisolone | No difference in LOS of hospitalization | Good evidence to suggest against use of OCS in viral-induced wheeze | |
| Foster et al (2018) (91) | Children aged 24–72 mo presenting to ED with viral-induced wheeze (n = 605) | RCT, double-blind, placebo-controlled, noninferiority trial, single dose of oral prednisolone to reduce ED LOS | Placebo group with longer LOS (540 min) versus prednisone group (370 min), single center, baseline very long LOS, unclear whether generalizable to different settings, unclear whether meaningful outcome studied) | ||
| Dupilumab (anti–interleukin-4 receptor α monoclonal antibody) for moderate to severe uncontrolled asthma | |||||
| Castro et al (2018) (92) | Children aged ≥12 y, uncontrolled asthma (n = 1902) | Randomized to 4 arms to receive add on dupilumab every 2 weeks versus placebo for 1 y at 2:2:1:1 ratio | Lower rates of severe exacerbation and better lung function; results better in children with higher baseline eosinophilia | Promising results, good evidence for use of dupilumab in severe uncontrolled asthma (93) | |
| Rabe et al (2018) (80) | Children age ≥12 y; OCS-dependent severe asthma (n = 210) | Random assignment of add-on dupilumab every 2 wk versus placebo for 24 wk in an attempt to reduce OCS dose | Improved lung function, decreased OCS dose, and fewer exacerbations in treatment group (small study) | ||
ED=emergency department, GINA=Global Initiative for Asthma, ICS=inhaled corticosteroid, LOS=length of stay, NAEPP=National Asthma Education and Prevention Program, OCS=oral corticosteroid, RCT=randomized controlled trial.