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AI-Generated response:

what is the recommendation for a 4 year old with severe asthma who has tried and failed ICS controller and montelukast?

Answer generated on June 4, 2024

The AI-generated responses are for illustration purposes only and should not be used for medical purposes.

For a 4-year-old with severe asthma who has failed inhaled corticosteroids and montelukast, the next recommended step is to add a long-acting beta2-agonist (LABA) to the high-dose inhaled corticosteroid, and consider a referral to an asthma specialist.[1]

  • Initiate daily high-dose inhaled corticosteroid plus inhaled long-acting beta2-agonist (LABA) with as-needed inhaled short-acting beta2-agonist to alleviate symptoms.[1]

  • Ensure proper inhaler technique and adherence to medication as these are critical for treatment effectiveness.[1]

  • Consider a trial of add-on oral corticosteroids if symptoms remain uncontrolled with the above regimen.[1]

  • Referral to an asthma specialist is recommended to evaluate further therapeutic options and management strategies.[1]

  • Monitor closely for potential side effects of high-dose inhaled corticosteroids, such as growth suppression, and the rare but serious risks associated with LABAs, such as severe asthma episodes.[1-2]

Additional info

In managing severe asthma in young children, it's crucial to ensure that the inhaler technique is correct and that the child is adhering to the prescribed regimen, as these factors significantly influence treatment outcomes. Referral to an asthma specialist can provide access to more comprehensive asthma management plans and potential enrollment in advanced therapeutic trials. It's also important to monitor for side effects associated with high-dose inhaled corticosteroids, especially in young children, as they can impact growth. Regular follow-ups to assess the efficacy of the treatment and adjust as necessary are essential to managing severe asthma effectively.

References

Reference 1

1.

Elsevier ClinicalKey Clinical Overview

Treatment Reduces exacerbations by 56% to 70%, reduces emergency department visits and hospitalization, provides small improvement in asthma symptoms and quality of life Approved for patients aged 12 years and older with severe asthma Peripheral blood eosinophil count or FeNO (fraction of exhaled nitric oxide) level is not required as these patients still have clinically significant clinical improvement, but higher blood eosinophil count and higher FeNO are predictors for better outcome If no evidence of type 2 inflammation, consider the following: Add-on tiotropium bromide, a long-acting muscarinic antagonist Course of low-dose oral corticosteroid Consider a trial of anti-TSLP (thymic stromal lymphopoietin) or anti–interleukin 4/anti–interleukin 13 Last resort is addition of low-dose oral corticosteroid EPR-4 recommendations for children with severe persistent asthma not controlled by step 4 treatments Referral to an asthma specialist is recommended for children of all ages Children aged 4 (EPR-4) years and younger Daily high-dose inhaled corticosteroid plus inhaled long-acting β₂-agonist with as-needed inhaled short-acting β₂-agonist to alleviate symptoms (preferred treatment for EPR-4) Alternatively, high-dose inhaled corticosteroid with montelukast and as-needed short-acting β₂-agonist Consider add-on oral corticosteroid as a step up to step 6 treatment Children aged 5 to 11 years Daily high-dose inhaled corticosteroid plus inhaled long-acting β₂-agonist with as-needed inhaled short-acting β₂-agonist to alleviate symptoms (preferred treatment for EPR-4) Alternatively, daily high-dose inhaled corticosteroid with leukotriene receptor antagonist or theophylline

Reference 2

2.

Corticosteroids, Inhaled (Respiratory), Elsevier ClinicalKey Drug Class Overview

Content last updated: March 5, 2024.

Because of the risks associated with higher doses of inhaled respiratory corticosteroids if patients older than 12 years require more than low-dose inhaled corticosteroids alone to control asthma, it is recommended to add long-acting beta2-agonists rather than increasing the dose of the steroid. The safety and efficacy of inhaled respiratory corticosteroids have not been studied adequately in children younger than 5 years. However, the National Asthma Education and Prevention Program Expert Panel recommends low-dose inhaled respiratory corticosteroids for the daily long-term therapy in children 0-4 years of age, along with close monitoring of the response to therapy[50599].

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