Higher dose inhaled corticosteroids in childhood asthma

What we do doesn't work and what we don't do does

Inhaled corticosteroids are the most effective regular prophylactic drugs for chronic persistent asthma in children. But uncertainty remains over the role of higher dosages (>400 μg/day beclomethasone equivalent) in treating persistent poorly controlled asthma; minor exacerbations in the community; or acute attacks.

For the symptoms of chronic persistent asthma the effectiveness of inhaled corticosteroids compared with placebo has been shown repeatedly in randomised controlled trials,1 and comparative trials have shown them to be more effective than sodium cromoglycate, nedocromil, theophylline, and long acting β agonists. This effectiveness has to be balanced against the possibility of adverse effects, but in routine use at lower dosages (≤400 μg/day) important adverse effects are rare. This much is widely accepted, although there are concerns about overdiagnosing asthma and overuse of inhaled steroids, particularly in children aged under 5.2 The diagnosis of asthma must be made carefully and regular prophylaxis started only if warranted by persistent symptoms. The dose of inhaled steroids should be periodically stepped down—and perhaps discontinued if a child remains asymptomatic for more than a month or two. Most parents do this anyway.

But what are the effects of increasing the dose? Increasing the dosage of inhaled steroids to obtain better control of persistent asthma is widely practised …