Daily Steroids May Not Be Needed for Wheezing

Nov. 23, 2011 -- Daily inhaled steroids are currently recommended for preschoolers with frequent wheezing who have a high risk for developing persistent asthma or high risk for severe asthma, but the treatment may cause a small decrease in their growth.

Now new research finds that less frequent treatment with higher doses of inhaled steroids works just as well to control wheezing with less overall exposure to the drug.

Researchers compared outcomes among 278 high-risk preschoolers treated with either the occasional inhaled steroid regimen or the recommended daily regimen.

They found the treatments to be equally effective for reducing the frequency of wheezing episodes that required the use of oral steroids over the course of a year.

The study appears in the Nov. 24 issue of The New England Journal of Medicine.

"We showed that daily treatment was not superior to intermittent treatment," says study researcher Robert S. Zeiger, MD, PhD, of the Childhood Asthma Research and Education (CARE) Network. "And even though the dose used in the intermittent regimen was four times higher than that used for daily treatment, the cumulative dosage was threefold lower among children in the study."

Daily Treatment With Inhaled Steroids

About half of children will have at least one wheezing episode before they enter kindergarten, but about 6% have frequent wheezing and other risk factors associated with persistent asthma, Zeiger tells WebMD.

Daily treatment with inhaled steroids is recommended for children under the age of 5 who have had at least four wheezing episodes during the previous year and other indications of high risk for persistent asthma. This includes having a parent with asthma or having eczema or airway allergies.

Zeiger says sticking to the daily regimen is far from best, with parents often forgetting to give the medication.

Several studies have also linked daily inhaled steroid use to a small but significant decrease in height. In one study, the height reduction was only partially reversed after children were off the treatment for a year.

In an earlier study, Zeiger and colleagues first showed that an occasional high-dose inhaled steroid regimen controlled wheezing in preschoolers.

The regimen included seven days of treatment started at the first sign of breathing symptoms associated with significant wheezing episodes.

Because these symptoms differ from child to child, parents completed questionnaires designed to identify the specific triggers for their own preschooler.

"This was an important component to ensure the treatment was not overused," Zeiger says. "If children were treated for every sniffle they would be on it every month and that would not be desirable."

Risk of Reduced Growth

The year-long study compared daily and occasional treatment with the inhaled steroid Pulmicort.

Children in the occasional group were treated, on average, every 3.5 months and their cumulative dose of the drug was 100 milligrams less over the course of the year than children treated every day with 0.5 milligrams.

More research is needed to determine if this treatment regimen is associated with a lower risk for impaired growth.

"The implication is that if you are giving less steroid overall there will be less impact on growth, but that remains to be seen," pulmonary specialist Len Horovitz, MD, of Lenox Hill Hospital in New York City tells WebMD. "It could be that there is more [bodily] absorption with the higher-dose intermittent regimen, even though the cumulative dose is not as great."

Horovitz says the occasional dosing schedule may be more attractive to parents because they don't have to remember to give the treatment every day.

"Parents know their own child's [wheezing] triggers, so I don't see the more complicated dosing as a big drawback."