Predictors for Failed Dose Reduction of Inhaled Corticosteroids in Childhood Asthma

Background And Objective: Studies of Western populations have shown that increased exhaled nitric oxide (FeNO) and/or sputum eosinophils (sp-Eos) are predictive of asthma exacerbations. However, the utility of these measurements in different populations and settings is unknown. This study aimed to determine the predictors for failure of reduction of inhaled corticosteroid (ICS) doses in children with stable asthma.

Methods: Fifty children (median age 11.8 years, interquartile range (IQR) 5.9 years) had their dose of ICS halved every 8 weeks until they reached the study end-point (exacerbation or weaned off ICS). Spirometry, FeNO and induced sputum cells were measured at baseline and at each stage of ICS reduction.

Results: Eleven subjects suffered an asthma exacerbation and the remainder was successfully weaned off ICS. Subjects with an exacerbation were older (15.4 years (IQR 5.4) vs 11.4 years (IQR 3.9), P = 0.019) and more likely to be boys (P = 0.035). FeNO (median 156 p.p.b. (IQR 131) vs 76.1 p.p.b. (IQR 79.5), P = 0.013) and sp-Eos (17.3% (IQR 33.8%) vs 7.1% (IQR 9.9%), P = 0.019) were significantly greater in those who had an exacerbation. The areas under the receiver operating characteristic curves for FeNO (0.78, 95% CI: 0.59-0.97, P = 0.013) and sp-Eos (0.76, 95% CI: 0.56-0.96, P = 0.016) were similar (P = 0.88) and both were significantly greater than that for FEV(1)% predicted (0.12, 95% CI: 0.08-0.56, P = 0.0013).

Conclusions: Older boys with raised FeNO and sp-Eos are at higher risk of failure of reduction in their ICS dose. Monitoring airway inflammation in children with asthma using FeNO or sp-Eos is clinically useful in guiding ICS dose reduction in a non-Western outpatient setting.