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Note to pediatricians: Taper meds in kids with stable asthma

July 07, 2008

Hopkins Children's study shows many doctors wouldn't

A study of how pediatricians prescribe asthma medications suggests that while most would readily increase a child's medication if needed, many are reluctant to taper off drug use when less might be best. A report on the study, led by Johns Hopkins Children's Center researchers, appears in the July issue of Pediatrics.

"Asthma medications can have serious, albeit infrequent, side effects, and while under-treatment is undeniably a big problem, not stepping down treatment when a child is doing well may be too," says lead investigator Sande Okelo, M.D., an asthma specialist at Hopkins Children's.

In the research, conducted among 310 pediatricians nationwide, 40 percent said they would not step down high-dose treatment even if a child's symptoms were well controlled and infrequent.

"If a child is doing well and her symptoms are well under control, why not take that chance and see if a smaller dose would do the trick?" says senior investigator Gregory Diette, M.D., M.H.S., a lung specialist at Hopkins.

Beyond side effects, Okelo says, a failure by pediatricians to taper off drugs may also lead parents to do so on their own by skipping doses or decreasing them.

"Past research shows that when parents are concerned about side effects and their child is doing well, they may take action without a doctor's approval," Okelo says.

For the study, the pediatricians were asked to devise treatment plans using different patient scenarios, describing various elements, including whether a child had been hospitalized recently, how bothersome and frequent a child's symptoms were, whether symptoms had recently intensified or lessened and whether the child had wheezing on a physical exam. Most doctors reported they would step up treatment in patients with:

1) recent hospitalizations
2) frequent symptoms
3) parents who said they were bothered by their child's symptoms
4) those who had wheezing on exam

While current treatment guidelines focus on symptom frequency, nearly all pediatricians reported using multiple factors in their decision-making, including quality of life and how bothered parents were by their child's symptoms.

Okelo says pediatricians might greatly benefit from a step-by-step, "frontlines" tool that tells them how to specifically apply treatment guidelines and how to use different dimensions of the disease in their day-to-day practice.

Because asthma is an unstable disease and can change often and unpredictably, it is essential that children with asthma get regular follow-up exams every three to six months even in the absence of symptoms, researchers recommend.

Johns Hopkins Medical Institutions