By Will Boggs MD
Source: Reuters - 16/7/2019
It's not clear which inhaled corticosteroids and delivery devices have the least adverse impact on growth in children with persistent asthma, a systematic review concludes.
Inhaled corticosteroid treatment is generally considered safe in children, but the potential adverse effects of these medications on growth remain a concern.
Dr. Linjie Zhang from Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil and colleagues assessed the impact of different inhaled corticosteroid drugs and delivery devices on the linear growth of children with persistent asthma in their July 16th Cochrane Database of Systematic Reviews.
In limited trials, fluticasone given at an equivalent dose was associated with significantly greater linear growth velocity than was beclomethasone (based on low certainty evidence) and appeared to have a less suppressive effect than budesonide on height change over an interval of 20 weeks to 12 months (based on moderate certainty evidence). Linear growth velocity, however, did not differ significantly between fluticasone and budesonide at equivalent doses.
In one trial, linear growth velocity was comparable when beclomethasone was administered at equivalent doses by two different metered dose inhalers, and a second trial found a small but significantly greater increase in height over a period of 6 months in favor of budesonide via Easyhaler compared with budesonide via Turbuhaler (based on low certainty evidence in both trials).
"The evidence from this systematic review of head-to-head trials is not certain enough to inform the selection of inhaled corticosteroid or inhalation device for the treatment of children with persistent asthma," the authors conclude. "Further trials are needed, and pragmatic trials and real-life observational studies seem more attractive and feasible."
Dr. David Skoner from West Virginia University School of Medicine, Morgantown, who has published numerous papers on the effects of inhaled corticosteroids on growth and bone health and has founded a nonprofit organization to raise awareness of inhaled corticosteroid dosing and side effects in children (www.macisteams.org), told Reuters Health by email, "Any inhaled corticosteroid delivered by any device at any dose is capable of suppressing the growth of children."
"Clinicians need to be aware of doses which have and have not been approved by the FDA for use in children," he said. "Studies have shown that clinicians are not aware that some of the doses approved by FDA for adults with asthma were not FDA-approved for children because of adrenal axis suppression. FDA-approved doses for children should be used first before higher non-FDA approved doses are used."
"Clinicians also need to proactively monitor for signs of corticosteroid excess, including growth, physical, and behavioral changes," Dr. Skoner said. "They need to listen to parents who say that they have noticed such changes in their children after starting inhaled corticosteroids."
"When inhaled corticosteroids were originally approved by the FDA for use in children, clinicians were afraid of them and their side effects, leading to under-use," he said. "The pendulum has now swung to the opposite side where they have very little fear of the side effects caused by these medications, even when prescribing excessive non-FDA approved doses for children. The pendulum needs to swing back the other way to some extent, i.e., in the direction of concern."
Dr. Yoon K. Loke from Norwich Medical School and the University of East Anglia in the UK, who earlier published a systematic review and meta-analysis that addressed the impact of inhaled corticosteroids on growth in children with asthma, told Reuters Health by email, "Despite years of research, we are still not able to say with great certainty whether any particular inhaled corticosteroid formulation or device is safer in terms of growth in children. At present, it probably doesn't matter which inhaled corticosteroid is used, so long as the asthma symptoms are well-controlled and the drug/device proves acceptable for the patient."
"Although there may be minor differences between products, inhaled corticosteroids probably do not have a hugely negative effect on children's growth, and it is just as important to optimize management of the persistent asthma," he said.
Dr. Zhang did not respond to a request for comments.
Cochrane Database of Systematic Reviews 2019.