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The principles of treatment of bronchial asthma in children
REVUEFRAN~AISE D ALLERGOLOGIE
66
ET D'IMMUNOLOGIE CLINIQUE
The principles of treatment of bronchial asthma in children R. KURZAWA, Z. DONIEC, U. J[~DRYS-KLUCJASZ, G. WILLIM
Bronchial asthma is the most frequent chronic disease of respiratory system in childhood. About 11-15 % of children, aged 0-18 years, suffer from asthma, while the disease is not correctly diagnosed and therefore incorrectly treated. The manner of pharmacological treatment was essentially influenced by the determination that chronic inflammatory process is the background of pathomechanism of asthma. The long-term inflammatory drugs became fundamental drugs in chronic regular treatment of bronchial asthma. These drugs reduce and inhibits inflammatory process by the prevention of the disease aggravations as well as its long-term effects irreversible changes of the bronchial structure leading to the decrease of the lung function. Drugs applied in the pharmacotherapy of the bronchial asthma are traditionally divided into two groups: • control drugs - systematically long-term applied anti-inflammatory drugs (inhaled glycocorticosteroids, disodium cromoglycate, nedocromil sodium, antileucotriens, slow-reacting theophyllin in low doses) and long-term 13-2 symphaticomimetics;
National Research Institute for TBC and Lung Diseases, Rabka Branch, ul. Polna 2, PL-34700 RABKA.
• symptoms relief drugs - e.g. short-term 13-2 symphaticomimetics applied if necessary, theophyllin, anticholinergic drugs and systemic glycocorticosteroids applied if necessary in the period of 3-10 days. Inhaled glycocorticosteroids are the most effective anti-inflammatory drugs in the treatment of bronchial asthma. These drugs can be applied in all clinical stages of chronic asthma (due to wide ranges of anti-inflammatory activity as well as good safety profile) and independently of age of patient (due to proper inhalation techniques). Disodium cromoglycate has lower antiinflammatory activity in comparison with inhaled glycocorticosteroids, and it is necessary to administrate them 3-4 times a day according to its pharmacological profile. Nedocromil sodium is more effective than disodium cromoglycate, its anti-inflammatory activity is comparable to low-doses of inhaled steroids, and can be used 2 times a day. Both m e n t i o n e d above drugs have the best safety profile and lead rarely to adverse events.
KURZAWA R., DONIEC Z., J~DRYS-KLUCJASZ U., WILLIM G . The principles of treatment of bronchial asthma in children. Flev. ft. Allergol., 1999, (Numero special), 66-68.
© Expansion Scientifique Publications, 1999
/ TREATMENT OF BRONCHIAL ASTHMA 1N CHILDREN • Table I. - Principles o f stepwise treatment o f bronchial asthma-children younger than 6 years.
Step 1 Episodic asthma
* Short-term 6-2 symphaticomimetics, if necessary, up to 2 times weekly
Step 2 Mild chronic asthma
• Disodium cromoglycate, 3-4 times daily (nebulization or MDI + "spacer") or • Nedokromi ! sodium, 2 doses 2 times daily (MDI+ "spacer") or • Inhaled glycocorticosteroids in low dose (50-100 gg/day, MDI + "spacer',) attention: the treatment should started by tile use of cromons
Step 3 moderate chronic asthma
," Nedokromil sodium, 2 doses 4-2 times daily (MDI + "spacer") or • Inhaled glycocorticosteroids in m e d i u m dose (100-200 gg/day, MDI + "spacer") or • Inhaled glycoc0rticosteroids in m e d i u m dose and nedokromil sodium or • Inhaled glycocorticosteroids in m e d i u m dose and slow-reacting theophyllin (5-10 m g / k g / d a y ) , long-term [~-2 symphaficomimetics in children older than 4 years (2x25 gg, MDI+"spacer")
Step 4 severe chronic asthma
• Inhaled glycocorficosteroids in high dose (200-400 btg/day, MDI + "spacer")+long-term [3-2 s)~nphatico-mimetics in Children older than 4 years (2x25 gg, MDI + "spacer") or • procedure as above + slow-reacting theophyllin (5-10 m g / k g / d a y )
Table II. - Principles o f stepwise treatment o f bronchial asthma-children older than 6 years.
Step 1 episodic asthma
I • Short-term 6-2 symphaticomimetics, if necessary, ] up to 2 times weekly
Step 2 mild chronic asthma
• Disodium cromoglycate, 3-4 times daily (nebulization or MDI + "spacer") or • Nedokromil sodium, 2 doses 2 times daily (MDI+"Synchroner") or • Inhaled glycocorticosteroids in low dose (100-200 btg/day, MDI+ "spacer", DPI) use of antileucotriens should be taken into consideration
Step 3 moderate chronic asthma
• Nedokromil sodium, 2 doses 4-2 times daily (MDI+ "Synchroner") or/and • Inhaled glycocorticosteroids in m e d i u m dose (300-400 gg/day, MDI + "spacer", DPI) and, if necessary, long-terna [3-2 symphaticomimetics or slow-reacting theophyllin (5-10 m g / k g / d a y ) use of antileucotriens should be taken into consideration, increase dose of inhaled steroids (500-800 gg/day) in case of symptoms
Step 4 severe chronic asthma
• Inhaled glycocorticosteroids in high dose (500-1000 gg/day, MDI + "spacer", DPI)+ long-term ~-2 symphaticomimetics • systemic glycocorticosteroids in 3-10 days period
Remarks to tables I and II: In case of all levels of asthma severity: 1. Short-term [~-2 symphaticomimetics, not frequent than 3-4 times daily. 2. Elimination of allergens and irritant factors. Rev.fr. Allergol., 1999, Num6ro sp6cial
67
68
• R. K U R Z A W A E T A L . /
Long-term acting methyloxantines have bronchorelaxation activity and in low doses (5-10 m g / kg/day) may present also anti-inflammatory activity. In the last years anti-leucotriens drugs were i n t r o d u c e d into the treatment of bronchial asthma. They can be used in children older than 6 years, as a supplementary treatment in chronic mild and moderate asthma, inhibit the synthesis of leucotriens, or blocked leucotriens receptors on the target cells. Long-term ~-2 symphaticomimetics (salmeterol, formoterol) can be administrate only together with inhaled steroids 2 times a day. They are used in the t r e a t m e n t of m o d e r a t e and severe bronchial asthma, especially in cases with night exacerbations. Short-term ~-2 symphaticomimetics (salbutamol, terbutalin, fenoterol) are used for treatment of asthma exacerbations, and are prescribed as different forms of aerosol according to the age of child. Anticholinergic drugs present weak bronchodilatation activity and are used generally in infants and young children.
Systemic glycocorticosteroids are used in the treatment of moderate and severe exacerbations of asthma, when ~-2 symphaticomimetics are not effective. In the treatment of bronchial asthma we are using stepwise approach. Range of applied pharmacotherapy is adjusted to the level of the severity. The efficacy of treatment should be evaluated every 1-6 months. The level of pharmacotherapy can be changed - reduced when the treatment is effective at least at 3 months period (step-down) - o r increased (step-up) when the treatment does not lead to the control of the clinical stares of patient. The principles of treatment of bronchial asthma according to the age are presented in tables I and II. REFERENCES 1. Droszcz W. -Astma oskrzelowa. Warszawa, PZWL, 1995. 2. Kurzawa R., Doniec Z., Jedrys-KNejasz U., Mazurek H., Bukowczan Z. - Wybrane problemy diagnostyki, prewencji i leczenia astray oskrzelowej w wieku rozwojowym. Rabka, IGiChP ZP, 1997. 3. Og61nogwiatowa startegia leczenia astmy oskrzelowej i jej prewencji. Raport NHLBI/WHO (polish edition), IGiChP, Warszawa, 1996.
mum
Rev.fr. AllergoL, 1999, Num6ro sp6cial
66
ET D'IMMUNOLOGIE CLINIQUE
The principles of treatment of bronchial asthma in children R. KURZAWA, Z. DONIEC, U. J[~DRYS-KLUCJASZ, G. WILLIM
Bronchial asthma is the most frequent chronic disease of respiratory system in childhood. About 11-15 % of children, aged 0-18 years, suffer from asthma, while the disease is not correctly diagnosed and therefore incorrectly treated. The manner of pharmacological treatment was essentially influenced by the determination that chronic inflammatory process is the background of pathomechanism of asthma. The long-term inflammatory drugs became fundamental drugs in chronic regular treatment of bronchial asthma. These drugs reduce and inhibits inflammatory process by the prevention of the disease aggravations as well as its long-term effects irreversible changes of the bronchial structure leading to the decrease of the lung function. Drugs applied in the pharmacotherapy of the bronchial asthma are traditionally divided into two groups: • control drugs - systematically long-term applied anti-inflammatory drugs (inhaled glycocorticosteroids, disodium cromoglycate, nedocromil sodium, antileucotriens, slow-reacting theophyllin in low doses) and long-term 13-2 symphaticomimetics;
National Research Institute for TBC and Lung Diseases, Rabka Branch, ul. Polna 2, PL-34700 RABKA.
• symptoms relief drugs - e.g. short-term 13-2 symphaticomimetics applied if necessary, theophyllin, anticholinergic drugs and systemic glycocorticosteroids applied if necessary in the period of 3-10 days. Inhaled glycocorticosteroids are the most effective anti-inflammatory drugs in the treatment of bronchial asthma. These drugs can be applied in all clinical stages of chronic asthma (due to wide ranges of anti-inflammatory activity as well as good safety profile) and independently of age of patient (due to proper inhalation techniques). Disodium cromoglycate has lower antiinflammatory activity in comparison with inhaled glycocorticosteroids, and it is necessary to administrate them 3-4 times a day according to its pharmacological profile. Nedocromil sodium is more effective than disodium cromoglycate, its anti-inflammatory activity is comparable to low-doses of inhaled steroids, and can be used 2 times a day. Both m e n t i o n e d above drugs have the best safety profile and lead rarely to adverse events.
KURZAWA R., DONIEC Z., J~DRYS-KLUCJASZ U., WILLIM G . The principles of treatment of bronchial asthma in children. Flev. ft. Allergol., 1999, (Numero special), 66-68.
© Expansion Scientifique Publications, 1999
/ TREATMENT OF BRONCHIAL ASTHMA 1N CHILDREN • Table I. - Principles o f stepwise treatment o f bronchial asthma-children younger than 6 years.
Step 1 Episodic asthma
* Short-term 6-2 symphaticomimetics, if necessary, up to 2 times weekly
Step 2 Mild chronic asthma
• Disodium cromoglycate, 3-4 times daily (nebulization or MDI + "spacer") or • Nedokromi ! sodium, 2 doses 2 times daily (MDI+ "spacer") or • Inhaled glycocorticosteroids in low dose (50-100 gg/day, MDI + "spacer',) attention: the treatment should started by tile use of cromons
Step 3 moderate chronic asthma
," Nedokromil sodium, 2 doses 4-2 times daily (MDI + "spacer") or • Inhaled glycocorticosteroids in m e d i u m dose (100-200 gg/day, MDI + "spacer") or • Inhaled glycoc0rticosteroids in m e d i u m dose and nedokromil sodium or • Inhaled glycocorticosteroids in m e d i u m dose and slow-reacting theophyllin (5-10 m g / k g / d a y ) , long-term [~-2 symphaficomimetics in children older than 4 years (2x25 gg, MDI+"spacer")
Step 4 severe chronic asthma
• Inhaled glycocorficosteroids in high dose (200-400 btg/day, MDI + "spacer")+long-term [3-2 s)~nphatico-mimetics in Children older than 4 years (2x25 gg, MDI + "spacer") or • procedure as above + slow-reacting theophyllin (5-10 m g / k g / d a y )
Table II. - Principles o f stepwise treatment o f bronchial asthma-children older than 6 years.
Step 1 episodic asthma
I • Short-term 6-2 symphaticomimetics, if necessary, ] up to 2 times weekly
Step 2 mild chronic asthma
• Disodium cromoglycate, 3-4 times daily (nebulization or MDI + "spacer") or • Nedokromil sodium, 2 doses 2 times daily (MDI+"Synchroner") or • Inhaled glycocorticosteroids in low dose (100-200 btg/day, MDI+ "spacer", DPI) use of antileucotriens should be taken into consideration
Step 3 moderate chronic asthma
• Nedokromil sodium, 2 doses 4-2 times daily (MDI+ "Synchroner") or/and • Inhaled glycocorticosteroids in m e d i u m dose (300-400 gg/day, MDI + "spacer", DPI) and, if necessary, long-terna [3-2 symphaticomimetics or slow-reacting theophyllin (5-10 m g / k g / d a y ) use of antileucotriens should be taken into consideration, increase dose of inhaled steroids (500-800 gg/day) in case of symptoms
Step 4 severe chronic asthma
• Inhaled glycocorticosteroids in high dose (500-1000 gg/day, MDI + "spacer", DPI)+ long-term ~-2 symphaticomimetics • systemic glycocorticosteroids in 3-10 days period
Remarks to tables I and II: In case of all levels of asthma severity: 1. Short-term [~-2 symphaticomimetics, not frequent than 3-4 times daily. 2. Elimination of allergens and irritant factors. Rev.fr. Allergol., 1999, Num6ro sp6cial
67
68
• R. K U R Z A W A E T A L . /
Long-term acting methyloxantines have bronchorelaxation activity and in low doses (5-10 m g / kg/day) may present also anti-inflammatory activity. In the last years anti-leucotriens drugs were i n t r o d u c e d into the treatment of bronchial asthma. They can be used in children older than 6 years, as a supplementary treatment in chronic mild and moderate asthma, inhibit the synthesis of leucotriens, or blocked leucotriens receptors on the target cells. Long-term ~-2 symphaticomimetics (salmeterol, formoterol) can be administrate only together with inhaled steroids 2 times a day. They are used in the t r e a t m e n t of m o d e r a t e and severe bronchial asthma, especially in cases with night exacerbations. Short-term ~-2 symphaticomimetics (salbutamol, terbutalin, fenoterol) are used for treatment of asthma exacerbations, and are prescribed as different forms of aerosol according to the age of child. Anticholinergic drugs present weak bronchodilatation activity and are used generally in infants and young children.
Systemic glycocorticosteroids are used in the treatment of moderate and severe exacerbations of asthma, when ~-2 symphaticomimetics are not effective. In the treatment of bronchial asthma we are using stepwise approach. Range of applied pharmacotherapy is adjusted to the level of the severity. The efficacy of treatment should be evaluated every 1-6 months. The level of pharmacotherapy can be changed - reduced when the treatment is effective at least at 3 months period (step-down) - o r increased (step-up) when the treatment does not lead to the control of the clinical stares of patient. The principles of treatment of bronchial asthma according to the age are presented in tables I and II. REFERENCES 1. Droszcz W. -Astma oskrzelowa. Warszawa, PZWL, 1995. 2. Kurzawa R., Doniec Z., Jedrys-KNejasz U., Mazurek H., Bukowczan Z. - Wybrane problemy diagnostyki, prewencji i leczenia astray oskrzelowej w wieku rozwojowym. Rabka, IGiChP ZP, 1997. 3. Og61nogwiatowa startegia leczenia astmy oskrzelowej i jej prewencji. Raport NHLBI/WHO (polish edition), IGiChP, Warszawa, 1996.
mum
Rev.fr. AllergoL, 1999, Num6ro sp6cial