What Color is Your Yellow Zone? Is There a Role for Escalation of Anti-inflammatory Therapy Short of an Oral Corticosteroid Burst?

Abstract

ABSTRACT

Current asthma management guidelines advise management of mild asthma exacerbations with short-acting beta agonists, followed by consideration of a short course of systemic corticosteroids. Problems with this approach include lack of effect of beta agonists on flareup progression, and the toxicity of systemic corticosteroids. There is a need for a management strategy for mild exacerbations intermediate between beta agonist only and addition of systemic corticosteroids. Randomized controlled clinical trials on doubling doses of inhaled corticosteroid AFTER an asthma exacerbation is established have shown no benefit; however, this strategy may be too little, too late. Other randomized controlled clinical trials have examined either escalation from low- to high-dose inhaled corticosteroid (quadrupling dose) or escalation of the inhaled corticosteroid concurrently with the beta agonist in an inhaler that combines both medications (i.e., one combination inhaled steroid + rapid acting beta agonist inhaler for both “maintenance” and “quick relief”). These studies have demonstrated significant benefit from the early and aggressive escalation of the inhaled corticosteroid component. Another randomized controlled clinical trial has demonstrated benefit from the intermittent use of montelukast with asthma flares in children who are well between flares. In contrast to the recommendations of current asthma guidelines, these recently published studies demonstrate that sufficient escalation of asthma controller therapy sufficiently early in an asthma exacerbation can reduce the progression of a mild exacerbation, and should be considered as a treatment option for the management of mild exacerbations of asthma. (Pediatr Asthma Allergy Immunol 2008; XX(X):XX–XX.)