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'Lack of solid evidence' on childhood asthma guidance

By Mark Pownall

Established GP guidance on when to use long-acting beta agonists (LABAs) in childhood asthma has been called into doubt by a new Cochrane review and is based on ‘a lack of solid evidence' say specialists.

For more than 10 years British Thoracic Society (BTS) guidelines have recommended adding an LABA at step 3 - if control is inadequate on low doses of inhaled corticosteroids.

But the guidelines are out of step with recommendations from other countries and the Cochrane review - of 25 trials carried out in 5572 children - says there is ‘insufficient evidence' to support LABAs at the BTS stage 3.

It found that adding LABAs had no significant effect on reducing the risk of exacerbations requiring oral steroids compared to inhaled steroids alone.

The Cochrane reviewers say the BTS guidelines ‘differ markedly' from those in other countries, some of which recommend adding a LABA only once children have tried high doses of inhaled steroids - 800 mcg of beclamethasone or equivalent.

The review also expresses concern about non-significant trends for those taking combined treatment that suggest more exacerbations needing oral steroids, admissions to hospital and serious adverse health events.

The review notes that adding a LABA to inhaled steroids improves lung function, but has no apparent effect on symptoms or the use of ‘rescue' short acting beta agonists.

GP Dr David Price, professor of primary care respiratory medicine at the University of Aberdeen said: ‘We need to be cautious here - there are a small number of studies and whilst there is little evidence of clinical benefit of LABAs in children there is little evidence of harm.

‘We are currently conducting a large government funded study of adding LABAs to ICS which should help answer this question.'

Plymouth GP Dr Rupert Jones, who has a special interest in respiratory disease, said: ‘This is a bit of a surprise as the guidelines clearly state we should add a LABA before increasing the ICS dose but it may be that the received wisdom in adults does not apply in children.'

‘But, on balance, I don't think it is enough to change current prescribing practice.'

Cochrane author Dr Muireann Ni Chroinin, a consultant paediatrician at Cork University Hospital said: ‘It's probably premature to change step 3, but we need to be cautious about the evidence we are basing our treatment on. Doubling the dose of inhaled steroid, is definitely an option to consider.'

A Cochrane review has called into doubt established guidance on using long-acting beta-agonists in childhood asthma A Cochrane review has called into doubt established guidance on using long-acting beta-agonists in childhood asthma

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