asthma step up treatment children

Question 1

guidelines depend on…

Answer 1

if you are under 5
or over 5-16

Question 2

1st line for asthma in over 5 yr olds

Answer 2

Start an inhaled short-acting beta2 agonist (such as salbutamol or terbutaline sulfate), to be used as required in all children with asthma.

Question 3

step up treatment if children over 5 present with any one of the following features: using an inhaled short-acting beta2 agonist three times a week or more, symptomatic three times a week or more, or waking at night due to asthma symptoms at least once a week.

Answer 3

A paediatric low-dose of ICS should be started as maintenance therapy
e.g. clenil 100mcg 2 puffs bd

Question 4

If asthma is uncontrolled on a paediatric low-dose of ICS as maintenance therapy in children over 5 what is the next step

Answer 4

consider a leukotriene receptor antagonist (LTRA—such as montelukast) in addition to the ICS, and review the response to treatment in 4 to 8 weeks.

dose for 6-14: 5mg OD in evening

Question 5

If asthma is uncontrolled on a paediatric low-dose of ICS and a LTRA as maintenance therapy in children over 5 what is the next step

Answer 5

consider discontinuation of the LTRA and initiation of a LABA in combination with the ICS.

Question 6

If asthma remains uncontrolled on a paediatric low-dose of ICS and a LABA as maintenance therapy in children over 5 what is the next step

Answer 6

consider changing to a MART regimen (Maintenance And Reliever Therapy—a combination of an ICS and fast-acting LABA such as formoterol in a single inhaler) with a paediatric low-dose of ICS as maintenance.

Question 7

what is the only MART inhaler licsensed for use in children 6-17 (others are 12-17) for maintenance therapy of asthma
and what is the dose

Answer 7

symbicort 100/6 turbohaler Initially 1–2 puffs twice daily; reduced to 1 puff daily, dose reduced only if control is maintained.

Question 8

for children over 5, if asthma remains uncontrolled on a MART regimen with a paediatric low-dose of ICS as maintenance what do you do

Answer 8

consider increasing to a paediatric moderate-dose of ICS (either continuing a MART regimen, or changing to a fixed-dose regimen of an ICS and a LABA with a short-acting beta2 agonist as reliever therapy).

Question 9

what do you do in children over 5 if asthma is still uncontrolled on a paediatric moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen)

Answer 9

consider seeking advice from an asthma specialist and the following options:

Increasing the ICS dose to a paediatric high-dose as maintenance (this should only be offered as part of a fixed-dose regimen with a short-acting beta2 agonist as reliever therapy), or
A trial of an additional drug, such as modified-release theophylline. DO NOT GIVE TIOTROPIUM, ONLY LICENSED FOR ADULTS!!

Question 10

name the 2 monoclonabl antibodies (specialist therapies) that can be considered in certain children with severe asthma to achieve control and reduce the use of oral corticosteroids

Answer 10

omalizumab and dupilumab

Question 11

what to give to all people under 5 with suspected asthma

Answer 11

A short-acting beta2 agonist (such as salbutamol) as reliever therapy

Question 12

what to do if child under 5 presents with any of the following features

asthma-related symptoms three times a week or more, experiencing night-time awakening at least once a week, or suspected asthma that is uncontrolled with a short-acting beta2 agonist alone.

Answer 12

Consider an 8-week trial of a paediatric moderate-dose of ICS
After 8 weeks, stop and monitor symptoms.
If symptoms did not resolve during trial, review for alternative diagnosis
If symptoms resolved but REOCCURED WITHIN 4 weeks of stopping, restart ICS at paediatric low dose as 1st line maintenance
If symptoms resolves but reoccured BEYOND 4 weeks after stopping, repeat 8 week trial of paediatric moderate dose of ICS

Question 13

If suspected asthma is uncontrolled in children aged under 5 years on a paediatric low-dose of ICS as maintenance therapy what is the next step

Answer 13

consider a leukotriene receptor antagonist (LTRA—such as montelukast) in addition to the ICS.

6 months - 5 years dose is 4mg OD bedtime

Question 14

If suspected asthma is uncontrolled in children aged under 5 years on a paediatric low-dose of ICS and a LTRA as maintenance therapy what is the next step

Answer 14

stop the LTRA and refer the child to an asthma specialist.

Question 15

summarise BTS for >5

Answer 15

1. SABA
2. if 5-12 give a very low dose ICS, and give low dose if >12 ICS
3. > 12: give LABA as fixed regimen or MART. if 5-12, give LTRA or LABA
4. CBA MAN

Question 16

summarise BTS for under 5

Answer 16

1. SABA
2. very low dose ICS as initial regular preventer therapy. if unable to take ICS, give LTRA
3. if uncontrolled on ICS, + LTRA
4. if uncontrolled on low dose ICS + LTRA, stop LTRA and refer to specialist