A recent study adds to evidence that symptom-based adjustment of medication works as well as provider-based adjustment for treating children and teens with mild persistent asthma.1,2
To treat symptoms of mild persistent asthma, US guidelines3 currently recommend daily use of a fixed-dose inhaled corticosteroid (ICS) supplemented with the quick-relief use of a short-acting beta-agonist (such as albuterol).
However, daily asthma control medications are often under-prescribed and underused. Studies have found use of daily ICS to be particularly low among African-American children, who carry a disproportionate burden of morbidity and mortality from asthma.4-6
While the traditional provider-based approach to asthma treatment typically involves daily use of ICS, the symptom-based approach allows patients to adjust their own ICS frequency, guided by their symptoms and need for albuterol. Patients take two puffs of ICS each time they take albuterol when experiencing asthma symptom.
To help inform decisions about managing mild persistent asthma in children and teens, a recent study compared the two treatment approaches. The study took place in primary care settings with African-American children and teens ages 6-17 with mild persistent asthma.
A PCORI-funded study found that, after one year, African-American children and teens ages 6-17 with mild persistent asthma receiving daily fixed-dose or as-needed ICS did not differ significantly in asthma control, asthma exacerbations, lung function, or quality of life. Children and teens in both groups had better asthma control at the end of the study than at baseline. Children and teens receiving as-needed ICS used about one-fourth of the ICS per month as children and teens receiving daily fixed-dose ICS.
|Finding||As need versus Daily fixed-dose ICS Use|
|Asthma Control||After six months, the changes in asthma control scores were not clinically or statistically significantly different between the groups.|
|Use of ICS||On average, children in the as-needed ICS group used significantly less ICS than children in the daily fixed-dose ICS group (526 µg/month versus 1,961 µg/month; p<0.0001).|
|Asthma Exacerbation||There was no clinically or statistically significant difference between the two groups for asthma exacerbations, emergency department visits, or time to first exacerbation.|
|Lung Function||There was no clinically or statistically significant change in lung function from baseline between the two groups.|
|Quality of Life||Researchers used two different tools to measure quality of life in children and their parents. Neither showed clinically nor statistically significant differences in quality of life between children and their parents in the as-needed ICS group and in the daily fixed-dose ICS group.|
|Asthma Management||More children and their parents in the as-needed ICS group felt that they, rather than their primary care physician, were taking charge of their asthma management.|
What Do Current Guidelines Say?
The National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute updated its clinical guidelines on asthma management in December 2020. The updated guidelines include the use of ICS as needed as a treatment option in people ages 12 and older with mild persistent asthma.3 As-needed ICS is standard practice in Europe and was added to the April 2019 Global Initiative for Asthma guidelines as an equally viable alternative strategy to daily ICS use, including for children with mild persistent asthma.7
Talking with Caregivers and Patients
A parent-friendly version of this update is available here to help support clinicians’ conversations with parents of children and teens mild persistent asthma. Topics for discussion with children and their parents may include:
➤ How to recognize when asthma symptoms may be worsening.
➤ The importance of ensuring that the ICS approach is documented and defined in the child’s Asthma Action Plan so that other caretakers (e.g., school nurses) can follow it if needed.
➤ Helping children, teens, and parents decide whether as-needed or daily fixed-dose ICS is the best option based on the family’s preferences, the child’s ability to take medication daily, and the child’s asthma control history. Questions to ask parents and children include:
- Which approach best fits your current lifestyle?
- What is most important to you when helping your child manage mild persistent asthma?
- Do you have concerns about the current treatment approach we are using to manage your child’s asthma?
➤ The importance of recognizing asthma symptoms and knowing when to use the control inhaler if using the as-needed ICS approach. The parent and child may need additional education and/or coaching.
➤ The importance of checking in periodically to assess asthma symptoms and how well the current management approach is working.
About the Study
In 2013, PCORI launched an initiative on Treatment Options for African Americans and Hispanics/Latinos with Uncontrolled Asthma. The initiative funded this study and others.
In this study, the research team randomly assigned 206 African American children and teens ages 6-17 with mild persistent asthma from the St. Louis, Missouri, area to receive daily fixed-dose or as-needed ICS for one year. In both groups, asthma coaches offered patients or their parents two to four asthma education sessions by phone. During the sessions, the coaches helped children and parents better recognize symptoms of asthma and learn how to use asthma medication.
Parents of children ages 6-11 completed a survey about how often their child had asthma symptoms at the start of the study and again every three months for a year. Adolescents ages 12-17 also completed the survey. The research team tested patients’ lung function at the start of the study and again one year later.
Read more about this study at www.pcori.org/Sumino282
1. © 2011–2021 Patient-Centered Outcomes Research Institute. “Comparing Two Ways to Manage Asthma in African-American Children -- The ASIST Study.” Last Updated September 30, 2020. https://www.pcori.org/Sumino282
2. Sumino K, Bacharier LB, Taylor J, et al. A Pragmatic Trial of Symptom-Based Inhaled Corticosteroid Use in African-American Children with Mild Asthma. J Allergy Clin Immunol In Practice. 2020; 8(1): 176-185 e2. https://doi.org/10.1016/j.jaip.2019.06.030
3. Cloutier MM, Baptist AP, Blake KV, et al. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146(6): 1217–70. https://doi.org/10.1016/j.jaci.2020.10.003.
4. Akinbami LJ, Moorman JE, Bailey C, et al. Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010. NCHS Data Brief. 2012;(94):1-8.
5. Wisnivesky JP, Lorenzo J, Lyn-Cook R, et al. Barriers to adherence to asthma management guidelines among inner-city primary care providers. Ann Allergy Asthma Immunol. 2008;101(3):264-270. https://doi.org/10.1016/S1081-1206(10)60491-7
6. Flores G, Snowden-Bridon C, Torres S, et al. Urban minority children with asthma: substantial morbidity, compromised quality and access to specialists, and the importance of poverty and specialty care. J Asthma. 2009;46(4):392-398. https://doi.org/10.1080/02770900802712971
7. Global Initiative for Asthma. Pocket Guide for Asthma Management and Prevention for Adults and Children Older than 5 Years. 2019. Accessed on March 28, 2020. https:/ƒ/ginasthma.org/wp-content/uploads/2019/04/GINA-2019-main-Pocket-Guide-wms.pdf
The information in this publication is not intended to be a substitute for professional medical advice. This update summarizes findings from a PCORI research award to Kaiser Permanente Washington Health Research Institute.
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