The case for oral steroids Why not ICS? Why not oral steroids?

The case for oral steroids Why not ICS? Why not oral steroids?
In Acute Loss of Asthma Control: always systemic steroids or add/increase the dose of ICS ? The case of ICS Some doubts The case for oral steroids Why not ICS? Why not oral steroids? What to do in practice? Attilio Boner University of Verona, Italy

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Yes Guidelines from the National Asthma Education and Prevention Program (2007) recommend managing mild asthma exacerbations with the addition of a short-acting beta agonist to the treatment regimen, and if response is incomplete, adding an oral corticosteroid. problems: Oral corticosteroid medications, although effective, have significant side effects, even in short bursts. Beta agonists relieves asthma symptoms but do not prevent a mild exacerbation from progressing to a severe exacerbation. Nonadherence to the daily use of long-acting controller medication is extremely common. Smith LA, Pediatrics. 2008;122(4): Finkelstein JA, Arch Pediatr Adolesc Med. 2002;156(6): corticofobia Farber HJ, Chest. 2016;150(3):

Dinakar C, Ann Allergy Asthma Immunol. 2014;113(2):143-159.
Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Yes Guidelines from the National Asthma Education and Prevention Program (2007) recommend managing mild asthma exacerbations with the addition of a short-acting beta agonist to the treatment regimen, and if response is incomplete, adding an oral corticosteroid. Addressing those problems a practice parameter from the American Academy ofAllergy, Asthma, and Immunology (2014) recommends initiation or escalation of inhaled corticosteroids for acute loss of asthma control. Dinakar C, Ann Allergy Asthma Immunol. 2014;113(2): problems: Oral corticosteroid medications, although effective, have significant side effects, even in short bursts. Beta agonists relieves asthma symptoms but do not prevent a mild exacerbation from progressing to a severe exacerbation. Nonadherence to the daily use of long-acting controller medication is extremely common. Smith LA, Pediatrics. 2008;122(4): Finkelstein JA, Arch Pediatr Adolesc Med. 2002;156(6): corticofobia Farber HJ, Chest. 2016;150(3):

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Yes Short-Course Oral Corticosteroids Are Not Completely Benign Short bursts of oral corticosteroid medication : 1) have substantial adverse behavioral effects, causing anxiety, mania, irritability, or aggressive behavior, or a combination.5,6 2) can cause transient hypothalamic-pituitary-adrenal axis suppression, increase blood pressure, and decrease responses to neoantigens.7,8 3) can predispose the patient to infections, with severe varicella infection and tuberculosis.9,10 4) frequent short courses of oral steroids decrease bone mineral density.11 Farber HJ, Chest. 2016;150(3):

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Yes Escalation After the Flare-Up Is Established Is Too Little Too Late. ICS are best at stabilizing normal airways and preventing an exacerbation from starting. Initiation or escalation is likely to be most effective at the moment that it starts to get more difficult to keep the airways normal. Studies that waited for symptom duration of 24 to 72 hours or a substantial decrease in peak expiratory flow, or both, before doubling the ICS dose showed no benefit.12-14 Farber HJ, Chest. 2016;150(3):

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Yes The Case for As-Needed Escalation of Inhaled Corticosteroid Medication Initiation or substantial escalation of the ICS dose at the onset of loss of asthma control does show benefit. The challenge is that the escalation needs to be substantial and started early. (premonitor symptoms) In adults on a low daily ICS dose, quadrupling the dose after the onset of an exacerbation reduced the need for oral corticosteroids Foresi A. Chest. 2000;117(2): In young children, an extremely high dose of fluticasone, 1,500 mg daily, administered at the first sign of an upper respiratory tract infection substantially decreased the need for oral corticosteroids (OR, 0.49) but at the cost of an unacceptable decrease in growth.16 Ducharme FM, N Engl J Med. 2009;360(4): Farber HJ, Chest. 2016;150(3):

Beer S, Arch Dis Child. 1987;62(4):345-8.
Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Yes The Case for As-Needed Escalation of Inhaled Corticosteroid Medication Prodromal features of asthma. Beer S, Arch Dis Child. 1987;62(4):345-8. Farber HJ, Chest. 2016;150(3):

Budesonide/formoterol maintenance plus reliever therapy:
a new strategy in pediatric asthma. Bisgaard H. Chest. 2006;130(6): % patients with severe exacerbations budesonide/formoterol (80 µg/4.5µg) as maintenance + terbutaline as reliever high-dose budesonide (320 µg) as maintenance + terbutaline as reliever budesonide/formoterol (80 µg/4.5 µg) as maintenance + reliever

49% 35% 31% 28% Frequency of exacerbations in 44 weeks follow-up
Use of beclomethasone dipropionate as rescue treatment for children with mild persistent asthma (TREXA) Martinez Lancet 2011;377:650 843 children and adolescents with mild persistent asthma aged 5–18 yrs. 4 treatment groups: twice daily beclomethasone with beclomethasone plus albuterol as rescue (combined group); twice daily beclomethasone with placebo plus albuterol as rescue (daily beclomethasone group); twice daily placebo with beclomethasone plus albuterol as rescue (rescue beclomethasone group); and twice daily placebo with placebo plus albuterol as rescue (placebo group). Frequency of exacerbations in 44 weeks follow-up 60 – 50 – 40 – 30 – 20 – 10 – 49% 35% 31% 28% p=0.07 p=0.07 p=0.03 Placebo no BDP Salb Daily BDPx2 Salb Combined BDPx2 BDP+Salb Rescue No BDP BDP+Salb Regular Rescue 28

Use of beclomethasone dipropionate as rescue treatment
for children with mild persistent asthma (TREXA) Martinez Lancet 2011;377:650 Frequency of treatment failure requiring oral steroids Regular Rescue Combined BDPx2 + BDP-Salb Daily BDPx2 + Salb Rescue no BDP + BDP-Salb Placebo no BDP + Salb 23% 8.5% 5.6% 2.8% 30

for children with mild persistent asthma (TREXA) Martinez Lancet 2011;377:650 Linear growth by treatment group Regular Rescue Combined BDPx2 + BDP-Salb Daily BDPx2 + Salb Rescue no BDP + BDP-Salb Placebo no BDP + Salb 31

for children with mild persistent asthma (TREXA) Martinez Lancet 2011;377:650 Interpretation: Children with mild persistent asthma should not be treated with rescue albuterol alone and the most effective treatment to prevent exacerbations is daily ICS. ICS as rescue medication with albuterol might be an effective step-down strategy for children with well controlled, mild asthma because it is more effective at reducing exacerbations than is use of rescue albuterol alone. Use of daily ICS treatment and related side-effects such as growth impairment can therefore be avoided. 32

REGULAR BECLOMETHASONE
Regular vs prn nebulized treatment in wheeze preschool children Papi Allergy 2009:64:1463 % FREE DAYS ns 276 symptomatic children with frequent wheeze, aged 1–4 years. 3-month nebulized treatment: ) 400 μg beclomethasone bid plus 2500 μg salbutamol prn; ) placebo bid plus 2500 μg salbutamol prn; ) placebo bid plus 800 μg beclomethasone/1600 μg salbutamol combination prn. p=0.034 70 – 60 – 50 – 40 – 30 – 20 – 10 – 69.6% 64.9% 61% REGULAR BECLOMETHASONE PRN SALBUTAMOL PRN COMBINATION

REGULAR BECLOMETHASONE
Regular vs prn nebulized treatment in wheeze preschool children Papi Allergy 2009:64:1463 % FREE DAYS ns 276 symptomatic children with frequent wheeze, aged 1–4 years. 3-month nebulized treatment: ) 400 μg beclomethasone bid plus 2500 μg salbutamol prn; ) placebo bid plus 2500 μg salbutamol prn; ) placebo bid plus 800 μg beclomethasone/1600 μg salbutamol combination prn. The effect of prn combination was no different from that of regular beclomethasone on the primary and on several important secondary outcomes. p=0.034 70 – 60 – 50 – 40 – 30 – 20 – 10 – 69.6% 64.9% 61% REGULAR BECLOMETHASONE PRN SALBUTAMOL PRN COMBINATION

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Yes Evidence Synthesis Studies that focused on doubling the inhaled corticosteroid dose after the asthma flare was established did not show benefit. The key factor in the studies showing benefit of as-needed inhaled corticosteroid escalation is early initiation and substantial escalation (4X). Extremely high ICS doses, however, should be avoided because of the concern about adverse effects on growth. Never use albuterol alone! Farber HJ, Chest. 2016;150(3):

Dinakar C, Ann Allergy Asthma Immunol. 2014;113:143-159.
Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? No/Yes ? Some doubts What is meant by loss of control? Is this the same as an exacerbation? A previously published practice parameter summarizes the goal of the yellow zone as “Responding to the symptoms of acute loss of control in the yellow zone with effective interventions can help prevent deterioration to the red zone, necessitating use of systemic corticosteroids and/or urgent medical care.” Dinakar C, Ann Allergy Asthma Immunol. 2014;113: Weinberger M. Chest. 2016;150(3):490-2.

not quite yet an exacerbation.
Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? No/Yes ? So what is meant by loss of asthma control? Does it differ from an exacerbation? Is it essentially a preexacerbation? Symptoms requiring increased reliever medication, especially with an increase in nocturnal symptoms, is a full-blown exacerbation by someone standards even though that is described as still in the yellow zone and not an actual exacerbation. Dinakar C, Ann Allergy Asthma Immunol. 2014;113: the loss of control, if not already an exacerbation, is considered to be potential, pending, or imminent but not quite yet an exacerbation. Weinberger M. Chest. 2016;150(3):490-2.

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? No/Yes ? So what is meant by loss of asthma control? Does it differ from an exacerbation? Is it essentially a preexacerbation? Symptoms requiring increased reliever medication, especially with an increase in nocturnal symptoms, is a full-blown exacerbation by someone standards even though that is described as still in the yellow zone and not an actual exacerbation. Dinakar C, Ann Allergy Asthma Immunol. 2014;113: As a parent, someone would certainly consider that an exacerbation, not just loss of control. Weinberger M. Chest. 2016;150(3):490-2.

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? No There is convincing data that early aggressive use of systemic steroids provides impressive clinical benefit for children having an acute exacerbation of asthma.6,11,12,13,14 The question then is, can increasing ICS from a maintenance dose previously associated with control prevent the need for an oral corticosteroid? Doubling the dose of ICS provided no therapeutic advantage.15 Quadrupling the dose was associated with a modest but not statistically significant decrease in subsequent requirement for oral corticosteroids. 16 ? = Weinberger M. Chest. 2016;150(3):490-2.

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? No Is there an advantage with regard to safety for a higher dose of inhaled corticosteroid compared with a short course of an oral corticosteroid? Sustained adverse effects from a short course of a corticosteroid has been examined and found to be absent.18 A Cochrane review of the subject concluded, “Practitioners may prescribe systemic corticosteroids in otherwise healthy children when indicated for the management of acute respiratory conditions (ie, infections or asthma exacerbations) with minimal concern about short-term adverse effects.”19 Fernandes RM. Evid-Based Child Health. 2014;9(3): Weinberger M. Chest. 2016;150(3):490-2.

Fernandes RM. Evid-Based Child Health. 2014;9(3):733-747.
The Cochrane Library and safety of systemic corticosteroids for acute respiratory conditions in children: an overview of reviews. Fernandes RM. Evid-Based Child Health. 2014;9(3): with corticosteroids there were significantly fewer admissions at day 1 (OR = 0.63, 95% confidence interval 0.52 to 0.78). 8.49 fewer hours in hospital compared with placebo. significantly fewer relapses leading to hospitalization (OR = 0.42, 95% confidence interval 0.23 to 0.76). 7 reviews containing 44 relevant randomized controlled trials

Triage nurse initiation of corticosteroids in pediatric asthma is associated with improved emergency department efficiency. Zemek R, Pediatrics Apr;129(4): Time to clinical improvement Physician-initiated phase(black) and nurse-initiated phase (gray). 644 consecutive children aged 2 to 17 years nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4.

Triage nurse initiation of corticosteroids in pediatric asthma is associated with improved emergency department efficiency. Zemek R, Pediatrics Apr;129(4): Time to clinical improvement Physician-initiated phase(black) and nurse-initiated phase (gray). Nurse-initiated phase children improved earlier compared to physician-initiated phase (median difference: 24 minutes; 95% confidence interval [CI]: 1–50; P = 0.04). Admission was less likely if children received steroids at triage (odds ratio = 0.56; 95% CI: 0.36–0.87) 644 consecutive children aged 2 to 17 years nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4.

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? No/Yes There are occasional exceptions to the use of oral corticosteroids: 1) patients with mild exacerbations that do not require urgent medical care or hospitalizations, quadrupling the ICS dose may provide satisfactory relief of symptoms. 2) patients who may experience acute adverse effects from oral steroids, such as a child with diabetes requiring insulin, a trial of increasing the inhaled corticosteroids may be justified. However, a short course of an oral corticosteroid is likely to provide greater assurance of more rapid improvement. For most children who have experienced troublesome exacerbations, a short course of an oral corticosteroid provides an acceptably safe and generally assured means of preventing an exacerbation from progressing. Weinberger M. Chest. 2016;150(3):490-2.

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Rebuttal to No What is loss of control? Are symptoms that need reliever medication a “full blown exacerbation”? Is the “yellow zone” simply a “procrastinator’s zone”? Should we just cut to the chase and give oral corticosteroid medication any time a child has symptoms of asthma? Farber HJ, Chest. 2016;150(3):

1.1 0.59 Independent parental administration of prednisone
in acute asthma: a double-blind, placebo-controlled, crossover study. Grant CC, Pediatrics. 1995;96(2 Pt 1): number of attacks resulting in outpatient visits during 1 year follow-up 78 children (2 to 14 years) who had made ≥ 2 outpatient (ED or primary-care clinic) visits for acute asthma in the preceding yr. 1 dose of prednisone (2 mg/kg up to 60 mg) or placebo if an asthma attack had not improved after a dose of the child's regular acute asthma medicine. 1.5 – 1.0 – 0.5 – 0.0 - P=0.004 1.1 0.59 prednisone placebo

1.1 0.59 Independent parental administration of prednisone
in acute asthma: a double-blind, placebo-controlled, crossover study. Grant CC, Pediatrics. 1995;96(2 Pt 1): The poorer outcome in the prednisone group was attributable primarily to significantly more visits made in the prednisone group by children ≤5 years of age (P = 0.009). number of attacks resulting in outpatient visits during 1 year follow-up 78 children (2 to 14 years) who had made ≥ 2 outpatient (ED or primary-care clinic) visits for acute asthma in the preceding yr. 1 dose of prednisone (2 mg/kg up to 60 mg) or placebo if an asthma attack had not improved after a dose of the child's regular acute asthma medicine. 1.5 – 1.0 – 0.5 – 0.0 - P=0.004 1.1 0.59 prednisone placebo

Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial. Oommen A, Lancet. 2003;362(9394): % children admitted to hospital Children aged 1-5 years admitted to hospital with viral wheeze were randomised to parent-initiated prednisolone (20 mg one daily for 5 days) or placebo for the next episode 51 received prednisolone and 69 placebo. 15 – 10 – 05 – 00 - 12% P=0.06 3% prednisone placebo

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Rebuttal to No Although oral corticosteroid medication has definite benefits for patients with a moderate to severe asthma exacerbation, these clinical trials suggest that for most patients, early initiation by parents is not beneficial. 4. Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001;1: CD Farber HJ, Chest. 2016;150(3):

Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Rebuttal to Yes A systematic review did find acute vomiting, transient behavioral changes, and sleep disturbances in 5.4%, 4.7%, and 4.3% of children, respectively, who were given a short course of an oral corticosteroid, predominantly prednisolone.3 3. Aljebab F, Choonara O, Conroy S. Systematic review of the toxicity of short-course oral corticosteroids in children. Arch Dis Child. 2016;101(4): However, vomiting is a formulation issue due to the extremely foul taste of some liquid formulations of prednisolone. Weinberger M. Chest. 2016;150(3):490-2.

pharmacotherapy recommendations
Empowering the child and caregiver: yellow zone Asthma Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475. Asthma Action Plans commonly are based on the traffic signal color-coded concept of: - green (go) - yellow (caution) red (danger) pharmacotherapy recommendations intervention needed asthma exacerbation requiring urgent treatment no change (

Early detection of asthma exacerbations by using
action points in self-management plans Honkoop PJ, Eur Respir J 2013;41:53-9 The use of action points in an 8-week peak flow chart with an exacerbation at the half-way point Daily symptoms and morning peak expiratory flows (PEFs) from two previous studies. predicting exacerbations.

Percentage of days with
Nonrespiratory symptoms before loss of asthma control in children. Newton L, JACI Pract 2013;1:304 Percentage of days with a nonusual symptom before and during a LOC episode (≥2 consecutive days with LR symptoms) Caregivers of children aged to 11 years with asthma. Diary cards daily for 16 weeks during cold and flu season. Likert scale from 1 to (3 represented baseline or usual; or 2, less than usual; and or 5, more than usual). Multiple nonrespiratory (NR) Upper respiratory (UR) signs and symptoms. Mood changes (MC) Lower respiratory tract (LR). Loss of asthma control (LOC)

changes in behavior (moody, irritability, tension)
Nonrespiratory symptoms before loss of asthma control in children. Newton L, JACI Pract 2013;1:304 Percentage of days with a nonusual symptom before and during a LOC episode (≥2 consecutive days with LR symptoms) Caregivers of children aged to 11 years with asthma. Diary cards daily for 16 weeks during cold and flu season. Likert scale from 1 to (3 represented baseline or usual; or 2, less than usual; and or 5, more than usual). Multiple nonrespiratory (NR) Upper respiratory (UR) signs and symptoms. Mood changes (MC) Lower respiratory tract (LR). Loss of asthma control (LOC) changes in behavior (moody, irritability, tension) and appearance (dry skin, eye swelling, sunken eyes) can be present 3 days before an exacerbations

changes in behavior (moody, irritability, tension)
A Low-Literacy Asthma Action Plan to Improve Provider Asthma Counseling: A Randomized Study Yin H S, Pediatrics. 2016;137:e changes in behavior (moody, irritability, tension)

% providers using explicit symptoms (eg, "ribs show when breathing," )
A Low-Literacy Asthma Action Plan to Improve Provider Asthma Counseling: A Randomized Study Yin H S, Pediatrics. 2016;137(1):e % providers using explicit symptoms (eg, "ribs show when breathing," ) 119 providers were randomly assigned (61 low literacy, 58 standard) Physicians at 2 academic centers randomized to use a low-literacy or standard action plan to counsel the hypothetical parent of child with moderate persistent asthma (regimen: -Flovent 110 μg 2 puffs twice daily, -Singulair 5 mg daily, -Albuterol 2 puffs every 4 hours as needed) 100 - OCS + ICS 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 00 OR=33.0 54.1% p<0.001 3.4% The low-literacy plan Standard plan

pharmacotherapy recommendations
Empowering the child and caregiver: yellow zone Asthma Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475. Asthma Action Plans commonly are based on the traffic signal color-coded concept of: - green (go) - yellow (caution) red (danger) pharmacotherapy recommendations intervention needed asthma exacerbation requiring urgent treatment no change The risk of a “false” start, or initiating YZ treatment when not needed, should be balanced with the risk of a “late” start, resulting in downstream morbidity. (

YZ therapy should be continued for a period of
Empowering the child and caregiver: yellow zone Asthma Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475. Asthma Action Plans commonly are based on the traffic signal color-coded concept of: - green (go) - yellow (caution) red (danger) pharmacotherapy recommendations intervention needed asthma exacerbation requiring urgent treatment no change Criteria proposed to identify the YZ: an increase in asthma symptoms (two or more times per day) asthma symptoms that do not improve or recur (within 4 h or less) after treatment with an inhaled SABA increase in nocturnal symptoms Peak flow decline ≥ 15% at <80% of personal best Since symptoms return to baseline sooner than objective measures of function, YZ therapy should be continued for a period of ≈ 2 weeks to ensure full recovery (

Empowering the child and caregiver: yellow zone Asthma Action Plan
Empowering the child and caregiver: yellow zone Asthma Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475. The yellow zone OCS Symptoms’ perception ICS 2 weeks of ICS x 2-4 100% lung function

Written action plans for asthma: an evidence-based review of the key components.
Gibson PG, Thorax. 2004;59(2):94-9. For individualised complete written action plans: the use of 2-4 action points and the use of both inhaled (ICS) and oral (OCS) corticosteroid consistently improved asthma outcomes. Action points based on personal best peak expiratory flow (PEF) consistently improved health outcomes while those based on percentage predicted PEF did not. trials (n=26) that evaluated asthma action plans as part of asthma self-management education

Written action plans for asthma: an evidence-based review of the key components.
Gibson PG, Thorax. 2004;59(2):94-9. Comparison of the effects of action plan components on hospital admissions for asthma Comparison of the effects of action plan components on mean peak expiratory flow (PEF) in asthma * *

in those not receiving daily controllers
Empowering the child and caregiver: yellow zone Asthma Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475. Intervention Strategies in the Yellow Zone progresses over days after exposure to a known trigger, such as at the onset of a viral RTI rapidly after a short-term exposure to allergens (furry animals) or irritants (fireworks) A yellow zone episode can occur in two ways: or In such situations include scheduled dosing step-up tactics such as quadrupling or higher doses of inhaled corticosteroids (ICS), or supplementation of moderate- to high-dose ICS in those not receiving daily controllers

in those not receiving daily controllers
Empowering the child and caregiver: yellow zone Asthma Action Plan. Dinakar C, Curr Allergy Asthma Rep. 2014;14(11):475. Intervention Strategies in the Yellow Zone progresses over days after exposure to a known trigger, such as at the onset of a viral RTI rapidly after a short-term exposure to allergens (furry animals) or irritants (fireworks) A yellow zone episode can occur in two ways: or Use oral corticosteroids very early + ICS In such situations include scheduled dosing step-up tactics such as quadrupling or higher doses of inhaled corticosteroids (ICS), or supplementation of moderate- to high-dose ICS in those not receiving daily controllers

Conclusions Increasing the dose of ICS may prevent deterioration if started early and with moderate-high dose (4X) at the very onset of deterioration. For children with no prodromal symptoms, for those with a clinical history of severe asthma exacerbations and particularly for those of mold allergy the combined use of OCS and ICS seem more appropriate.

The case for oral steroids Why not ICS? Why not oral steroids?

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The case for oral steroids Why not ICS? Why not oral steroids?

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