Anti-inflammatory

Pearls of Wisdom: Corticosteroids

Case: Tiffany is a 9-year-old girl with asthma that has recently progressed from intermittent to mild persistant classification. The increased frequency of her symptoms occurred when she got a kitten for Christmas, but she would sooner give up a kidney than her Fluffy.

You have recommended, as per current guidelines, institution of inhaled corticosteroids (ICS) on a daily basis. Mom is concerned because Tiffany is only 4’6” tall and she has heard that ICS can result in growth retardation. 

How do you respond?

A. ICS does not reduce ultimate adult height attained.
B. Because inadequately treated asthma also results in growth retardation, it is an equal tradeoff.
C. ICS may reduce ultimate adult height attained.
D. Don’t worry about adult height. Smaller people are cuter.

What advice would you give?
(Answer and discussion on next page)


 

Louis Kuritzky. MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).

Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.

 

Answer: ICS may reduce ultimate adult height attained

Guidelines currently recommend that when asthma is characterized as intermittent, use of inhaled short-acting beta agonists (eg, alberterol) is appropriate. When asthma status intensifies to the level of persistent asthma, corticosteroids (ICS) are suggested as preferred maintenance therapy.
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Over the past 40 years, the debate on steroids in asthma hinges upon three facets: steroid toxicity, benefit, and asthma toxicity. That is, it has long been opined that uncontrolled asthma may be associated with impaired growth, that deleterious airway remodeling may occur unless appropriate anti-inflammatory intervention (ie, ICS) is provided, and that systemic steroid levels attained with “typical” doses of ICS are unlikely to impede growth or bone integrity. 

Prior opinion has also suggested that if ICS is discontinued when asthma remits (as it does in many teens and young adults), subsequent growth compensates for earlier possible deficits.

Research

Scientists recently reviewed data from the Childhood Asthma Management Program, in which asthmatic children (age 5-13) had been randomized to ICS (budesonide at 400 mcg/d), cromone (nedocromil at 16 mg/d), or placebo, for a period of 4 to 6 years.1 Follow-up to measure adult height attained occurred at a mean age of 25 years.

The result: Subjects who had been treated with ICS had a mean adult height attained that was 1.2 cm less than in the placebo group; height attained in the nedocromil group was not significantly different from placebo.

ICS and Adult Height1

height 

Over 3,000 persons each year die from asthma.2 The deaths in asthma are not predictable; that is, they are approximately evenly divided amongst those with mild, moderate, and severe asthma. Hence, there is no easy way to securely identify the truly high-risk individual. Accordingly, we want to offer the best possible asthma control—with the least possible consequences—to every patient.

What’s the “Take Home”?

In the recent past, we have tried to reassure parents of children who are concerned about potential growth impact of ICS that it either does not occur, if it occurs there will be a period of “catch-up,” or that the alternative of not treating asthma with steroids leads to its own important toxicities. However, a balanced discussion of the risk-benefit issues in asthma should now point out that literature indicates several years of ICS can lead to a modest (<1/2 inch) decrease in ultimate attained height.

References:

  1. Kelly HW, Sternberg AL, Lescher R, et al. Effect of inhaled glucocorticoids in childhood on adult height. NEJM. 2012;367(10):904-912.
  2. CDC. Asthma FastStats. Avaialble at: http://www.cdc.gov/nchs/fastats/asthma.htm. Accessed March 2014.