Severe Asthma in Children: Therapeutic Considerations

Louise Selby; Sejal Saglani


Curr Opin Allergy Clin Immunol. 2019;19(2):132-140. 

In This Article

Other Therapeutic Considerations

Muscarinic Antagonists

Long-acting muscarinic antagonists such as tiotropium bromide are bronchodilators which work via nonspecific blockade of the muscarinic acetylcholine receptor, inhibiting smooth muscle contraction and mucus secretion.[28] The Global Initiative for Asthma guideline includes tiotropium as add-on therapy at step 4 and 5 of asthma management in patients aged more than 12 years[47] following results of a phase-III 48-week double-blind placebo-controlled parallel-group study in adolescents. This showed significantly improved lung function when tiotropium was used in addition to ICS maintenance therapy.[48] Two phase-III trials with the primary aims of analyzing safety and efficacy of once-daily tiotropium in children aged 1–5 and 6–11 years have been undertaken but were not limited to severe asthma.[49,50] In total, 402 children aged 6–11 years were randomized to placebo, low or high-dose tiotropium. Primary endpoint was change from baseline response in forced expiratory volume in one second (FEV1) within 3 h of dosing. Secondary outcomes included symptom control, symptom-free days, weekly mean rescue medication use and peak flow response. Tiotropium showed a significant improvement in spirometry, not symptom scores.[50] There are no specific data of the efficacy of long-acting muscarinic antagonists in STRA, but given this data and impact on lung function, it is an attractive option, especially in children with markedly reduced lung function.