What Is the Role of Increasing Inhaled Corticosteroid Therapy in Worsening Asthma in Children?

The treatment of "yellow zone," or worsening, asthma in children remains controversial. The 2018 Global Initiative for Asthma strategy recommends increasing the dose of inhaled corticosteroid (ICS) for the short (1-2 weeks) or longer (3 months) term in children older than 5 years with worsening asthma. In contrast, the National Heart, Lung, and Blood Institute's Expert Panel Report 3 guideline for the diagnosis and management of asthma notes that doubling the dose of ICS therapy is "not sufficient" in worsening asthma, as does the Canadian Thoracic Society guideline on asthma management in children. Both guidelines do comment that higher than double dosing may be effective. In particular, the Expert Panel Report 3 guideline specifies that more than doubling the dose of ICS therapy may be useful in the emergency department management of worsening asthma, because it may prevent oral corticosteroid requirement. The Canadian Thoracic Society suggests that adolescents (older than 12 years) quadruple ICS maintenance dosing by 4- or 5-fold for 7 to 14 days with worsening asthma if there is a history of a severe exacerbation in the past year. All these recommendations were published before a recent, large randomized double-blind controlled trial by Jackson et al that further calls into question the efficacy of increased ICS dosing in worsening asthma in children. The goal of this Rostrum was to review available data and consider the role of increasing doses of ICS and potential alternative approaches to this common practice.