LONG-TERM THERAPY WITH INHALED CORTICOSTEROIDS IN PRESCHOOL CHILDREN CANNOT CHANGE THE NATURAL COURSE OF ASTHMA

Key words: Preschool children, Wheezing, Asthma, Natural history, Inhaled steroids

Background Airway chronic inflammation and remodelling play an important role in the pathophysiology of asthma, leading to structural irreversible changes of the airways which occur already in the early school years. Objective To determine whether a long-term anti-inflammatory treatment with inhaled steroids could limit the progression of asthma in preschool children at high risk, after their first episodes of wheezing. Selection of Studies Three recent double blind randomised controlled trials vs. placebo have been considered. Inhaled steroids were administered following different strategies. Results In the Peak Study inhaled fluticasone (88 mg twice daily) or placebo were given for two years regularly followed by a one-year period without therapy, to children of 2-or-3-years of age with a positive asthma predictive index and four or more episodes of wheezing in the prior year. During the treatment period there was a better control of symptoms in the fluticasone group, but in the third year all clinical benefits disappeared. In the IFWIN study 0.5 to 4.9-year old children with at least one atopic parent, after two episodes of wheezing lasting more than 24 hours or one wheezing episode lasting more than one month, were randomised to receive either placebo or inhaled fluticasone at the minimum dose needed to control symptoms until five years of age. There was no difference between the 2 groups in the proportion of children with current asthma. In both the PEAK and IFWIN studies a temporary slowing in the child’s growth was noticed. In the PAC study infants (mean age 10.7 months), whose mothers had asthma, were randomised to receive either inhaled budesonide (400 mg/day) or placebo once daily during any episode of wheezing lasting for at least three days in the first three years of life. There were no difference between the two groups in symptoms control and in progression to persistent wheezing. Conclusions The administration of continuous or intermittent inhaled steroids during the first years of life does not change the natural course of asthma. Given its potential risks, such prolonged therapy should be avoided.