Daily corticosteroids may not be best for intermittent wheezing

Although current clinical guidelines call for daily low-dose inhaled corticosteroid treatment for preschoolers who have recurrent wheezing and are at risk for developing asthma, that may not be the best course of action.

The regular low doses are no more effective than intermittent high doses in controlling symptoms, according to a study funded by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. The study found that giving 4 times the daily low dose only when needed worked just as well as regular dosing and had the added benefit of requiring one-third the total amount of medication per year. In fact, researchers found that treatment was necessary only an average of every 3.5 months when the children exhibited respiratory symptoms that had led to wheezing in the past.

It also improved compliance. "Recurrent wheezing in these very young children is a big problem. Parents and caregivers are reluctant to give them medicine every day when the wheezing episodes occur only a few times a year," said Susan B. Shurin, MD, acting director of the NHLBI.

For the study, called the Maintenance and Intermittent Inhaled Corticosteroids in Wheezing Toddlers (MIST) trial, researchers at 7 sites monitored 278 preschool children between the ages of 1 and 4.5 years who were considered at high risk of developing asthma and had wheezing episodes during respiratory illnesses, although they were relatively symptomless between episodes. The children were randomly assigned to 1 of 2 groups-the first where they were treated daily with low doses of the inhaled corticosteroid budesonide (Pulmicort Respules 0.5 mg, once nightly) and the other where participants were treated with a high dose of budesonide (2 mg per day) for 7 days only when respiratory symptoms were present.

No difference was found between the 2 treatment groups using several measurements, including: number of exacerbations (ie, episodes requiring oral corticosteroids); severity of respiratory symptoms; number of symptom-free days; number of doctor visits due to symptoms; absenteeism, whether from school, day care, or parental workplace; or quality of life.

"Our study offers a treatment option for wheezing preschoolers. A critical element of the intermittent approach is that parents were taught to start the intermittent regimen so it was not used for every respiratory illness or symptom,” said the study's principal investigator, Robert Zeiger, MD, PhD, of the University of California, San Diego, and Kaiser Permanente Southern California in San Diego. He cautioned that the study focused on preschoolers who wheeze during respiratory illnesses and not on children with persistent symptoms or more severe disease.

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