Stepwise Pharmacological Approach to Severe Childhood Asthma

  • Ina St. Onge
  • Karen M. McDowell
  • Theresa W. GuilbertEmail author


The stepwise approach to pharmacological therapy for severe asthma in children and adolescents is largely based on national and international guidelines, and the mainstay of therapy for this population remains inhaled corticosteroids with the addition of another controller medication. The preferred additional controller medication in older (school-age) children and adolescents is long-acting beta-agonist (LABA) delivered in a combination device, and if needed, additional therapies include a leukotriene receptor antagonist (LTRA), theophylline if levels can be monitored and drug-drug interactions minimized, or the addition of tiotropium. In younger (preschool) children, the preferred step-up is to double the inhaled corticosteroid (ICS) dose and assess response after 3 months. Alternatively, an LTRA may be added to low-dose daily ICS, but this is extrapolated from data of older children. Atopy and blood eosinophils can predict greater short-term response to moderate-dose ICS than to LTRA. The next step-up includes biologic therapies, currently only licensed for school-age children. For children that remain poorly controlled with these regimens, oral corticosteroids as a controller therapy can be considered for a brief period of time, and once symptoms are controlled, every effort should be made to step-down therapy to avoid adverse effects. More comparison studies are needed to identify the most efficacious treatment regimens by clinical phenotype in children with severe asthma.


Severe asthma Step-up Corticosteroids Long-acting beta-agonist (LABA) Long-acting muscarinic antagonist (LAMA) Leukotriene receptor antagonist (LTRA) Azithromycin Theophylline 


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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Ina St. Onge
    • 1
  • Karen M. McDowell
    • 1
  • Theresa W. Guilbert
    • 1
    Email author
  1. 1.Division of Pulmonary Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of MedicineCincinnatiUSA

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