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
undertreatment is undeniably a big problem, not stepping
down treatment when a child is doing well
may be, too," said lead investigator Sande Okelo, an asthma
specialist at Johns
Hopkins Children's Center.
In the nationwide research, 40 percent of the 310
pediatricians surveyed 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," said senior
investigator Gregory Diette, a lung specialist at
Beyond the issue of side effects, Okelo said, 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 said.
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 and (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 said 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, the researchers
recommend that children with asthma get regular follow-up
exams every three to six months, even in
the absence of symptoms.
Asthma is the most common pediatric chronic illness,
affecting 6.5 million children in the United
States, according to the Centers for Disease Control and
The study was funded by the National Heart, Lung and
Blood Institute. Other Johns Hopkins
investigators on the study are Cecilia Patino, Kristin
Riekert, Barry Merriman, Andrew Bilderback,
Nadia Hansel, Kathy Thompson, Jennifer Thompson and Cynthia
Rand. Other institutions involved in
the study include Howard University.