sign101

4.3.2 ADD-ON THERAPy
Options for add-on therapy are summarised in Figure 3.
In adult patients taking inhaled steroids at doses of 200-800 micrograms BDP/day and in children
taking inhaled steroids at a dose of 400 micrograms/day the following interventions are of value:
first choice would be the addition of an inhaled long-acting β agonist (LABA), which improves
2
312,316,317, 854-857
lung function and symptoms, and decreases exacerbations.
leukotriene receptor antagonists may provide improvement in lung function, a decrease
310,319,320 ,858
in exacerbations, and an improvement in symptoms.
theophyllines may improve lung function and symptoms, but side effects occur more
commonly. 313
slow-release β agonist tablets may also improve lung function and symptoms, but side
2
effects occur more commonly. 312
A B The first choice as add-on therapy to inhaled steroids in adults and children
(5-12 years) is an inhaled long-acting β 2 agonist, which should be considered
before going above a dose of 400 micrograms BdP or equivalent per day and
certainly before going above 800 micrograms BdP.
If, as occasionally happens, there is no response to inhaled long-acting β 2 agonist, stop the
LABA and increase the dose of inhaled steroid to 800 micrograms BDP/day (adults) or 400
micrograms BDP/day (children) if not already on this dose. If there is a response to LABA, but
control remains suboptimal, continue with the LABA and increase the dose of inhaled steroid
to 800 micrograms/day (adults) or 400 micrograms/day (children 5-12 years). 318
B The first choice as add-on therapy to inhaled steroids in children under five
years old is leukotriene receptor antagonists.
d d if asthma control remains suboptimal after the addition of an inhaled long-
acting β 2 agonist then the dose of inhaled steroids should be increased to 800
micrograms/day in adults or 400micrograms day in children (5-12 years),
if not already on these doses.
; If control remains inadequate after stopping a LABA and increasing the dose of inhaled
steroid, consider sequential trials of add-on therapy, ie leukotriene receptor antagonists,
theophyllines, slow-release β 2 agonist tablets (this in adults only).
Addition of short-acting anticholinergics is generally of no value. 314,321 Addition of nedocromil
is of marginal benefit. 304,315
4.3.3 SAFETy OF LONG-ACTING β 2 AGONISTS
4 PhArMAColoGiCAl MAnAGeMent
Following a review in 2007 of LABA in the treatment of adults, adolescents, and children with
asthma, the Medicines and Healthcare products Regulatory Agency (MHRA) further reviewed
the use of LABA, specifically in children younger than age 12 years and concluded that the
benefits of these medicines used in conjunction with inhaled corticosteroids in the control of
asthma symptoms outweigh any apparent risks. 859
; Long-acting inhaled β 2 agonists should only be started in patients who are already on
inhaled corticosteroids, and the inhaled corticosteroid should be continued.
>12
years
1 ++
1 ++ 1 ++ 1 +
1 + 1 -
1 ++
4 4
>12
years
1 +
5-12
years
1 ++
5-12
years
43