Pediatric severe asthma: a case series report and perspectives on anti-IgE treatment

Abstract

BackgroundThe primary goal of asthma management is to achieve disease control for reducing the risk of future exacerbations and progressive loss of lung function. Asthma not responding to treatment may result in significant morbidity. In many children with uncontrolled symptoms, the diagnosis of asthma may be wrong or adherence to treatment may be poor. It is then crucial to distinguish these cases from the truly “severe therapy-resistant” asthmatics by a proper filtering process. Herein we report on four cases diagnosed as difficult asthma, detail the workup that resulted in the ultimate diagnosis, and provide the process that led to the prescription of omalizumab.Case presentationAll children had been initially referred because of asthma not responding to long-term treatment with high-dose inhaled steroids, long-acting β2-agonists and leukotriene receptor antagonists. Definitive diagnosis was severe asthma. Three out four patients were treated with omalizumab, which improved asthma control and patients’ quality of life. We reviewed the current literature on the diagnostic approach to the disease and on the comorbidities associated with difficult asthma and presented the perspectives on omalizumab treatment in children and adolescents. Based on the evidence from the literature review, we also proposed an algorithm for the diagnosis of pediatric difficult-to-treat and severe asthma.ConclusionsThe management of asthma is becoming much more patient-specific, as more and more is learned about the biology behind the development and progression of asthma. The addition of omalizumab, the first targeted biological treatment approved for asthma, has led to renewed optimism in the management of children and adolescents with atopic severe asthma.

New Drugs for Pediatric Asthma

“…Severe asthma identifies children or adolescents who need high-dose ICS therapy and a second controller therapy in the previous year, or systemic corticosteroids for 50% of the year, to prevent asthma from being uncontrolled or that remains uncontrolled notwithstanding these medications (9). Unfortunately, once excluded any comorbidity or optimized patients' adherence to treatment and inhalation technique, about 5–10% of the asthmatic pediatric population continue to have severe symptoms or signs and the loss of lung function may be progressive and irreversible (70). The latter point is of paramount importance in view of the fact that a stringent relationship between the childhood insults to the lung and the accelerated aging that can occur in adult chronic obstructive lung disease has been postulated (71).…”

Paediatric and adult bronchiectasis: Specific management with coexisting asthma, COPD, rheumatological disease and inflammatory bowel disease

“…Children with uncontrolled asthma require high‐dose inhaled corticosteroids (ICS) in association with a long‐acting β 2 ‐agonist (LABA) plus oral leukotriene receptor antagonist or additional strategies, particularly anti‐IgE treatment . There are no trials of ICS in children or adolescents with non‐CF, bronchiectasis‐associated asthma or COPD, and the existing adult studies show minimal and, in most cases, no clinically significant benefits .…”

Asthma: Differential Diagnosis and Comorbidities

“…Establishing the real impact and the causative effect of comorbidities on asthma control it is complicated, and a medical treatment is sometimes necessary to assess their role ( 52 ). In most cases, although the ability to improve pediatric severe asthma by treating comorbidities remains unconfirmed, a therapeutic trial should be prescribed.…”