Drug maintenance treatment

- Current asthma guidelines focus on reaching asthma control and not on the severity of asthma. The asthma phenotype is taken into account when adjusting medication beyond step 2. Both concepts have not been prospectively validated in children. - Unchanged is the use of a β2agonist as required (step 1) and an inhaled corticosteroid when maintenance treatment is needed (step 2). For children under the age of 6, extra fine particle aerosols may be considered. In children who only have symptoms with viral infections a LTRA may be an alternative for ICS. - Before medication is increased, the diagnosis, concomitant disease (e.g. allergic rhinitis), adherence with treatment and persistent exposure to irritants, environmental tobacco smoke and allergens should be considered. - If asthma is well controlled for longer than three months, stepping down to a previous medication level is recommended. - If asthma is not well controlled despite inhaled steroids, the steroid dose should be doubled or a LTRA added when signs and symptoms of continuing inflammation are present (step 3). Adding a long acting bronchodilator is recommended if a bronchodilator response has been demonstrated (only when age > 4 years). There is no evidence to support which of these choices is to be preferred in children with asthma. - If control is not reached despite step 3 medication, and taking the above into consideration, doubling of ICS and/or adding a leukotriene receptor antagonist or a long-acting bronchodilator is recommended, depending on previous choices. - If LABA prove to be ineffective, they are discontinued. - Refractory symptoms despite step 4 treatment is managed according to the difficult asthma guideline.

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