Balanced programmes in the management of asthma in children ...

Asthma management in children should consist of a balanced programme of treatment, including prophylactic therapy, and involving several treatment strategies. Exposure to environmental or nutritional allergens should be reduced or eliminated. Significant decreases in the incidence of wheezing and medication use, and improved PEFA have been achieved in studies where asthmatic childrens' bedrooms have been kept dust-free. It is not clear whether treatment is necessary for children exhibiting decreased spirometric variables and PEFR in the absence of clinical asthma symptoms.

Many patients receive (j-agonists as their initial and sole bronchodilator treatment, achieving satisfactory bronchodilatation with correct dosage and inhalation technique. Inhaled (j-agonists are preferable initially because treatment can be self­administered as required, with supervision. Fluorocarbon propellants are currently not considered to produce significant cardiovascular adverse effects because of their short half-lives. Additional treatments, including environmental control and physiotherapy, are necessary to prevent overdependence on (j-agonists, adverse effects and tachyphylaxis.

Oral methylxanthines are well established bronchodilators . Single-agent formulations are currently preferred and theophylline is a drug of choice for long term maintenance treatment However, the limitations of theophylline treatment include the narrow therapeutic window, the need for regular plasma theophylline evaluations, adverse effects and the inconsistent relationship between plasma theophylline concentrations and prevention of bronchoconstriction. Enprofylline and other new methylxanthines appear to produce significant bronchodilatation independently of effects on adenosine.

Sodium cromoglycate produces few adverse effects and is a first-line inhaled treatment for asthma prophylaxis and stabilisation of bronchial hyper-reactivity. It acts principally by preventing mediator release from sensitised cells, protecting against challenges with aerosolised allergens and natural exposure to allergens. Inhaled sodium cromoglycate also prevents bronchoconstriction induced by cold dry aI(, exerCise, distilled water and industrial chemicals or pollutants, and produces significant Improvements In asthma symptoms and PEFA. However. the main disadvantage of sodium cromoglycate treatment is the need for administration more than twice daily, which may not be necessary with the new cromoglycate-like compounds such as nedocromil.

Routine anticholinergic treatment IS not advisable for asthmatic children. although inhaled atropine-like drugs are used for hospitalised patients and status asthmaticus.

Corticosteroids would be the antiasthmatic

4 INPHARMA" 11 Feb 1989

drugs of choice if they did not produce serious adverse effects including growth retardation and adrenal suppression. They are important agents in the treatment of acute asthmatic emergencies, but the suitability of long term treatment should be carefully considered. When other treatments have proved unsatisfactory corticosteroids may be indicated and adverse effects can be minimised by alternate-day treatment or the use of small inhaled doses of the newer poorly absorbed corticosteroids, including beclomethasone dipropionate and triamcinolone acetonide which exert significant topical effects . Pretreatment with bronchodilators and systemic corticosteroids will Increase the benefits of inhaled corticosteroids. Failiers CJ Global perspectives In the management of asthma Journal of Asthma 25 285·291 . Oct 1988 ''' '

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