BNF for Children 2011-2012

BNFC 2011–2012 3.1 Bronchodilators 135Management of chronic asthmaImportant Start at step most appropriate to initial severity; before initiating a new drug consider whetherdiagnosis is correct, check compliance and inhaler technique, and eliminate trigger factors for acute exacerbationsChild 5–18 yearsStep 1: occasional relief bronchodilatorInhaled short-acting beta 2 agonist as required (up to oncedaily)Note Move to step 2 if needed more than twice a week, or ifnight-time symptoms more than once a week, or if exacerbationin the last 2 yearsStep 2: regular inhaled preventer therapyInhaled short-acting beta 2 agonist as requiredplusRegular standard-dose 1 inhaled corticosteroid (alternatives2 are considerably less effective)Step 3: inhaled corticosteroid + inhaled long-actingbeta 2agonistInhaled short-acting beta 2 agonist as requiredplusRegular standard-dose 1 inhaled corticosteroidplusRegular inhaled long-acting beta 2 agonist (salmeterol orformoterol)If asthma not controlledIncrease dose of inhaled corticosteroid to upper end ofstandard dose range 1andEither stop long-acting beta 2 agonist if of no benefitOr continue long-acting beta 2 agonist if of some benefitIf asthma still not controlled and long-acting beta 2agonist stopped, add one ofLeukotriene receptor antagonistModified-release oral theophyllineStep 4: high-dose inhaled corticosteroid + regularbronchodilatorsInhaled short-acting beta 2 agonist as requiredwithRegular high-dose 3 inhaled corticosteroidplusInhaled long-acting beta 2 agonist (if of benefit)plusA 6-week sequential therapeutic trial of one or more ofLeukotriene receptor antagonistModified-release oral theophyllineModified-release oral beta 2 agonistStep 5: regular corticosteroid tabletsRefer to respiratory paediatricianInhaled short-acting beta 2 agonist as requiredwithRegular high-dose 3 inhaled corticosteroidandOne or more long-acting bronchodilators (see step 4)plusRegular prednisolone tablets (as single daily dose)Note In addition to regular prednisolone, continue high-doseinhaled corticosteroid (in exceptional cases may exceedlicensed doses)Stepping downReview treatment every 3 months; if control achievedstepwise reduction may be possible; reduce dose ofinhaled corticosteroid slowly (consider reduction every 3months, decreasing dose by up to 50% each time) to thelowest dose which controls asthmaChild under 5 years 4Step 1: occasional relief bronchodilatorShort-acting beta 2 agonist as required (not more thanonce daily)Note Preferably by inhalation (less effective and more sideeffectswhen given as tablets or syrup)Move to step 2 if needed more than twice a week, or if nighttimesymptoms more than once a week, or if exacerbation inthe last 2 yearsStep 2: regular preventer therapyInhaled short-acting beta 2 agonist as requiredplusRegular standard-dose 1 inhaled corticosteroidOr leukotriene receptor antagonist if inhaled corticosteroidcannot be usedStep 3: add-on therapyChild under 2 years:Refer to respiratory paediatricianChild 2–5 years:Inhaled short-acting beta 2 agonist as requiredplusRegular standard-dose 1 inhaled corticosteroidplusLeukotriene receptor antagonistStep 4: persistent poor controlRefer to respiratory paediatricianStepping downRegularly review need for treatment1. Standard doses of inhaled corticosteroidsBeclometasone dipropionate or budesonide:Child under 12 years 100–200 micrograms twice daily;Child 12–18 years 100–400 micrograms twice daily.Fluticasone propionate:Child 4–12 years 50–100 micrograms twice daily;Child 12–18 years 50–200 micrograms twice daily.Mometasone furoate:Child 12–18 years 200 micrograms twice daily.Note Dose adjustments may be required for some inhalerdevices, see under individual preparations section 3.22. Alternatives to inhaled corticosteroid are leukotrienereceptor antagonists, theophylline, inhaled nedocromil, orinhaled cromoglicate3. High doses of inhaled corticosteroidsBeclometasone dipropionate or budesonide:Child 5–12 years 200–400 micrograms twice daily;Child 12–18 years 0.4–1 mg twice daily.Fluticasone propionate:Child 5–12 years 100–200 micrograms twice daily;Child 12–18 years 200–500 micrograms twice daily.Mometasone furoate:Child 12–18 years up to 400 micrograms twice daily.Note Dose adjustments may be required for some inhalerdevices, see under individual preparations section 3.2.Failure to achieve control with these doses is unusual, seealso Side-effects of Inhaled Corticosteroids, section 3.24. Lung-function measurements cannot be used to guidemanagement in those under 5 yearsAdvice on the management of chronic asthma is based on the recommendations of the British Thoracic Society and ScottishIntercollegiate Guidelines Network (updated June 2009); updates available at www.brit-thoracic.org.uk3 Respiratory system