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Optimal treatment for virus-induced wheezing remains unknown
The results of two recently published studies raised questions regarding the most appropriate method for managing symptoms of virus-induced wheezing in preschool-age children.
The researchers conducted the studies to examine oral prednisolone and high-dose fluticasone as treatment options for young children experiencing acute, episodic, virus-induced wheezing.
Data from a double blind, randomized, placebo-controlled trial indicated that a five-day course of oral prednisolone did not significantly reduce the length of hospitalization among 700 study participants aged between 10 and 60 months. Median time to discharge was 13.9 hours in the placebo group and 11 hours in the treatment group. Also, treatment did not reduce the severity of symptoms as assessed by physicians or parents.
In a separate triple blind, randomized, placebo-controlled study, the researchers examined the safety and efficacy of preemptive high-dose inhaled fluticasone. At the onset of upper respiratory tract infections, 129 children aged 1 to 6 years were administered 750 mcg of fluticasone propionate or placebo twice daily for a maximum of 10 days.
Data indicated that children receiving fluticasone experienced milder symptoms of a shorter duration and had reduced use of rescue oral corticosteroids compared with those who received placebo (8% vs. 18%; OR=0.49; 95% CI, 0.30-0.83). However, patients receiving the drug also experienced less height and weight gain compared with children receiving placebo, suggesting the possibility for long-term adverse events.
“Because the adverse effects of preemptive treatment with fluticasone are still unknown, the potential risks associated with fluticasone treatment currently outweigh the identified benefits,” the researchers wrote.
An editorial accompanying both studies suggested that inhaled beta2-adrenergic agonists and prophylactic or intermittent use of leukotriene receptor antagonists “may be beneficial.” – by Nicole Blazek
N Engl J Med.2009;360:329-338,339-353,409-410.
The conundrum continues concerning the use of steroids as a treatment for wheezing in young children. Most preschool children who wheeze experience intermittent bouts that are triggered by common respiratory viruses. Some children are atopic and will go on to develop persistent, multi-trigger wheezing. It is difficult to predict the phenotype that preschool children will develop and treatment is aimed at symptom relief.
In the study by Panickar and colleagues (NEJM. 2009;360:329) no treatment benefit was observed with a five-day course of oral prednisolone compared with placebo. In a separate study by Ducharme and colleagues (NEJM. 2009;360:339) smaller gains in height and weight observed in children who received preemptive high-dose fluticasone compared with those who received placebo argue against its use in clinical practice despite the benefit of reduced use of rescue corticosteroids. Both studies also support limiting the use of oral prednisolone to those children who are hospitalized with severe virus–induce wheezing.
– Pedro A. Piedra, MD
Baylor College of Medicine, Houston