In black children with uncontrolled asthma, stepping up inhaled glucocorticoids beneficial

USA: Data from 280 black children aged 5-11 years with poorly controlled revealed that almost half of the children showed superior response to increased inhaled glucocorticoids and almost half had a superior response to the addition of a long-acting beta-agonist (LABA), according to a recent study published in The New England Journal of Medicine.

Morbidity from asthma is disproportionately higher among black patients than among white patients, and black patients constitute the minority of participants in trials informing treatment.

Previous data have indicated that patients with inadequately controlled asthma benefit more from the addition of a LABA than from increased glucocorticoids; however, these data may not be informative for treatment in black patients.

Michael E. Wechsler, of National Jewish Health, Denver, and colleagues reported results of two parallel BARD (Best African American Response to Asthma Drugs) trials conducted at nine centres between January 2014 and March 2016 of individuals with poorly controlled asthma.

One trial included 280 children aged 5-11 years (average age, 8.5 years); the second trial included adolescents aged 12 years and older and adults (average age, 37 years) who had family backgrounds that were similar to those of the children.

The children were randomized to four groups to compare the following protocols: doubling the dose of a glucocorticoid (fluticasone propionate) to a dose of 100 mcg, twice daily (the double-fluticasone group); doubling the dose of fluticasone to 100 mcg and adding 50 mcg of the LABA salmeterol (the salmeterol/double-fluticasone group); quintupling the dose of fluticasone to 250 mcg (the quintuple-fluticasone group); or quintupling the dose of fluticasone to 250 mcg and adding 50 mcg of salmeterol (the salmeterol/quintuple-fluticasone group). The trial consisted of a four-way crossover design with each treatment period lasting 14 weeks.

The primary outcome was a composite measure including asthma exacerbations, asthma control days, and percentage of predicted forced expiratory volume in the first second at the end of each treatment.

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Key findings include:

• When quintupling the dose of fluticasone (to 250 μg twice a day) was compared with adding salmeterol (50 μg twice a day) and doubling the fluticasone (to 100 μg twice a day), a superior response occurred in 46% of the children with quintupling the fluticasone and in 46% of the children with doubling the fluticasone and adding salmeterol.


• More adolescents and adults had a superior response to added salmeterol than to an increase in fluticasone (salmeterol–low-dose fluticasone vs. medium-dose fluticasone, 49% vs. 28%; salmeterol–medium-dose fluticasone vs. high-dose fluticasone, 49% vs. 31%.


• Neither the degree of African ancestry nor baseline biomarkers predicted a superior response to specific treatments.


• The increased dose of inhaled glucocorticoids was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years of age.

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In the adolescent and adult study using the same treatment protocols, 20%-25% of patients did not have a differential outcome between treatments. “In adolescents and adults, the addition of a LABA was more likely to produce superior responses than increasing the dose of an inhaled glucocorticoid,” wrote the researchers.