Black kids respond differently to step-up asthma therapy

  • Wechsler ME & al.
  • N Engl J Med
  • 26 Sep 2019

  • International Clinical Digest
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Takeaway

  • Black children with poorly controlled asthma respond equally well to higher glucocorticoid dose or higher glucocorticoid dose plus newly added long-acting beta-agonist (LABA).
  • Black adolescents and adults respond similarly to white children and adults: they have a superior response to the addition of LABA than to an increased glucocorticoid dose.

Why this matters

  • The guidelines emphasize the introduction of LABA, based on data from white children and adults. They may have to be modified for black children.

Study design

  • Two randomized, double-blind, 4-treatment, 4-period, 56-week cross-over trials: 1 in black children (aged 5-11 years; n=280) and 1 in black adolescents and adults (aged ≥12 years; n=294).
  • At baseline, children were receiving 50 μg fluticasone propionate (FP, a glucocorticoid), and adolescents/adults were receiving 100 μg FP (all doses twice daily). 
  • Primary outcome: a composite of asthma exacerbations, asthma-control days, and lung function.
  • Funding: NIH.

Key results

  • Children: no difference in response to higher glucocorticoid dose (250 μg FP) vs higher glucocorticoid dose plus addition of LABA (100 μg FP/50μg salmeterol [SM], a LABA): 46% vs 46%, respectively (P=.99).
  • Adolescents/adults: superior response to the addition of SM than to an increase in FP.
    • 100 μg FP/50 μg SM vs 250 μg FP (49% vs 28%, respectively; P=.003).
    •  250 μg FP/50 μg SM vs 500 μg FP (49% vs 31%, respectively; P=.02).

Limitations

  • Larger, more simplified, treatment trial needed for children.