Pediatric Asthma Deserves Special Considerations

Dr. Brown is an assistant professor ofpharmacy practice at Palm BeachAtlantic University, Lloyd L. GregorySchool of Pharmacy, Palm Beach,Florida.

Asthma&#8212;a condition associatedwith chronic inflammation,bronchial hyperresponsiveness,and typically reversible bronchospasms&#8212;affects children more commonlythan adults. The illness leads tomissed days at school, frequent emergencydepartment (ED) visits, a reductionin quality of life, increased health carecosts, and even death.^1,2 In 2004, 6.2 millionchildren <18 years of age werereported to have asthma, and, of these,3.9 million children had an asthmaattack.³

The highest prevalence of asthmaoccurs in children aged 5 to 17 years, and~40% of children who have parents withasthma will develop the condition. Inaddition, the rate of asthma occurring inchildren <5 years old increased by morethan 160% from 1980 to 1994.^3,4

Despite these alarming statistics,appropriate treatment, monitoring, andpatient education can control asthmaand its symptoms and allow patients tolive fully active lives.

The Role of Corticosteroids

Because inflammation is a hallmarkfinding in patients with asthma, the useof corticosteroids is a rational treatmentoption to minimize deleterious effects onthe lungs. The use of these drugs in pediatricpatients, however, is a commonconcern among health care providersand parents, particularly with regard totheir adverse-event profile.

Frequent concerns relate to a reductionin the rate of linear (ie, vertical)growth and bone mineral density. Therisk for these adverse effects is greater inpatients receiving systemic corticosteroids,as opposed toinhaled corticosteroids(ICSs). Nonetheless, concernremains regardingthe safety of ICSs in children.

In the Childhood AsthmaManagement Programstudy, which included1041 children aged 5to 12 years with mild-tomoderateasthma, thosereceiving inhaled budesonideexperienced adelay in linear growth ofabout 1.1 cm during thefirst year of therapy,compared with thosereceiving nedocromil orplacebo. Growth velocitywas similar in all groupsduring subsequent yearsof treatment, however. In addition, bonemineral density of the lumbar spine wasnot reduced in the patients receivingICS therapy.⁵

Overall, ICSs may decrease the shorttermlinear growth rate in children, butthe effects are small and may be partiallyreversible. ICS therapy does not appearto be associated with sustained reductionswith continued treatment.^5-7 Additionally,the effect on linear growthdoes appear to be dose-related, with thehighest potential associated with highdoseICS therapy.

ICSs are associated with far feweradverse effects, however, when comparedwith systemic corticosteroids,especially for the treatment of severepersistentasthma.⁸

In the Expert Panel Report 3, theNational Asthma Education and PreventionProgram continues to recommendICSs for the management of mildpersistent,moderate-persistent, andsevere-persistent asthma as the mosteffective maintenance therapy.⁸ To minimizesystemic absorption of ICSs andultimately to reduce the risk for theseadverse effects as well as oral thrush,patients should be counseled to rinsewith water and spit following the administrationof ICSs. The use of devices suchas spacers and valved holding chambersalso have been shown to reduce the riskfor oral candidiasis.⁸

Albuterol Versus Levalbuterol in Pediatric Patients

Short-acting beta₂ agonists such asalbuterol and levalbuterol are used frequentlyin acute exacerbations, especiallyin the ED, to quickly alleviate bronchospasms.Albuterol is a 50:50 racemicmixture of the R- and S-enantiomers,whereas levalbuterol consists only of theR-enantiomer, which is responsible forbronchodilation. In addition, levalbuterolhas a greater binding affinity to the beta₂receptor to produce its bronchodilatoreffects. Airway reactivity associated withalbuterol use is attributed to the S-enantiomerin the racemic mixture&#8212;which isthe reason why levalbuterol was developed.⁹

Because of the increased expenseassociated with levalbuterol, expertshave raised questions regarding its efficacy,compared with that of albuterol. In1 study, 129 children between 2 and 14years old, who were seen in the ED foracute moderate or severe asthmaattacks, were given weight-based dosesof albuterol or levalbuterol via nebulizerfor 5 treatments, along with oral systemiccorticosteroids following the seconddose and ipratropium following thethird dose. The researchers noticed nodifferences between the 2 groups withregard to clinical asthma scores, hospitalizationrates, or pulmonary-functiontest results.¹⁰

Another study with children aged 1 to18 years, seen in the ED for acute asthmaexacerbations, found that those treatedwith levalbuterol had fewer hospitalizations,compared with those who weretreated with albuterol (36% vs 45%,respectively). The length of hospital stay,however, was not significantly differentbetween the 2 groups.^11,12

Although the findings from these studiesare mixed, appropriate administrationof a short-acting beta₂ agonist, eitheralbuterol or levalbuterol, during an acuteasthma exacerbation is most critical toreduce morbidity and mortality.

Administration Technique

Medications used in the managementof asthma are available in various devices,including metered dose inhalers (MDIs),dry-powder inhalers (DPIs), and nebulizers.Pediatric patients may be reluctant touse these devices or may experience difficultywhen trying to use them appropriately.Proper inhalation technique is vitalto ensure adequate drug delivery and tominimize adverse drug reactions. A tablelisting the steps for appropriate use ofMDIs can be found here.

o n l i n e

For proper techniques for usingasthma management devices,go to www.PharmacyTimes.com/AsthmaDevices.

Solutions given via nebulizers may bea better option for younger patients whohave difficulty maneuvering devices,because nebulizers do not require significantmanual coordination while beingadministered. The disadvantages of usingnebulizers may include a longer period oftime to receive treatment, as well asinconvenience, because these devicesare not as easily transported from hometo school or day care, compared withother devices.

MDIs may be difficult for pediatricpatients to actuate appropriately usinghand-breath coordination. To increasemedication delivery to the lungs, spacersor valved holding chambers may be recommended,because these devices"hold" the dose of medication to allow thepatient more time to inhale appropriately.

Pharmacist's Role

Pharmacists can play a vital role in themanagement of pediatric patients withasthma. Patient education, especiallyregarding appropriate inhalation technique,is essential to ensure adequatemedication delivery. Providing handoutswith pictures of appropriate inhaler technique,as well as asking patients todemonstrate technique after properinstruction, may be useful, particularlywith children.

Recommendations regarding the useof spacers, valved holding chambers, orface masks may be necessary for pediatricpatients who have difficulty withmanual coordination of MDIs. In addition,patients who frequently refill shortactingbeta₂ agonists such as albuterol(ie, >1 canister every 1-2 months) maybe candidates for referral to their primarycare physicians, because frequentuse of quick-relief medications (ie, >2days per week for symptom relief) is typicallyconsidered an indicator of poorlycontrolled asthma. Regular use of shortactingbeta₂ agonists also is associatedwith an increased risk for asthma exacerbations.⁸

Emphasis on daily administration ofcontroller medications such as ICSs isimportant to reduce the risk for asthmaattacks. Refill reminders on maintenancemedications may increase patient adherence,as some patients may discontinuetreatment because they have no symptoms.

Pharmacists may be asked by concernedparents or caregivers about theimpact of ICS therapy on linear growth.Proper education about the minimal risksversus the potential benefits of therapymay be warranted. It is important to emphasizethat, even though ICS therapymay impact linear growth slightly, therealso is a risk for delayed growth in childrenwho have poorly controlled asthma.⁸ Methods to minimize systemicabsorption (ie, rinsing with water andspitting after administration and spacerusage) also may be provided.

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Do the case scenarios on asthmaat www.PharmacyTimes.com/PediatricAsthmaCase

In addition, pharmacists may be involved in the development of written asthma action plans in conjunction with patients' physicians. These action plans provide steps to be taken based on lung function, which is determined from peakflow meter readings and which helps detect the onset of an asthma attack,even if the patient is feeling well. Writtenasthma action plans are especiallyimportant for those patients who havemoderate- to severe-persistent asthmaor who have a history of poorly controlledasthma. Development of a writtenasthma action plan for school also maybe warranted.⁸

Increasing awareness of special considerations for pediatric patients with asthma can help improve quality of life, decrease health care costs, maximize functional capacity, and prevent deaths.

References

• Williams D. Strategies for optimizing treatment of acute and chronic asthma. Introduction: asthma epidemiology and economic impact. Am J Health Promot. 2006;63(10 suppl 3):S3-S4.
• Schreck DM. Asthma pathophysiology and evidence-based treatment of severe exacerbations. Am J Health Promot. 2006;63(10 suppl 3):S5-S13.
• American Lung Association. Trends in asthma morbidity and mortality. American Lung Association Web site. www.lungusa.org/atf/cf/~ASTHMA06FINAL.PDF. Accessed September 20, 2007.
• American Academy of Asthma, Allergy and Immunology. Asthma statistics. www.aaaai.org/media/resources/media_kit/asthma_statistics.stm. Accessed February 5, 2007.
• Kelly HW, Strunk RC, Donithan M, et al. Growth and bone density in children with mild-moderate asthma: a cross-sectional study in children entering the Childhood Asthma Management Program (CAMP). J Pediatr. 2003;142:286-291.
• Leone FT, Fish JE, Szefler SJ, West SL. Systematic review of the evidence regarding potential complications of inhaled corticosteroid use in asthma. Chest. 2003;124:2329-2340.
• Witzmann KA, Fink RJ. Inhaled corticosteroids in childhood asthma. Drugs 2000;59(suppl 1):9-14.
• National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung, and Blood Institute Web site. www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed September 20, 2007.
• Pleasants RA. Focus on inhaled beta2 agonists: efficacy, safety and patient preference. Pharmacotherapy. 2004;24(5 pt 2):44S-54S.
• Qureshi F, Zaritsky A, Welsh C, Meadows T, Burke BL. Clinical efficacy of racemic albuterol versus levalbuterol for the treatment of acute pediatric asthma. Ann Emerg Med. 2005;46:29-36.
• Carl JC, Myers TR, Kirchner HL, Kercsmar CM. Comparison of racemic albuterol and levalbuterol for treatment of acute asthma. J Pediatr. 2003;143:731-736.
• Blake K. Review of guidelines and the literature in the treatment of acute bronchospasms in asthma. Pharmacotherapy. 2006;26(9 pt 2):148S-155S.