コントロール不良の小児喘息における低用量ステロイド吸入のステップアップ治療の根拠は？といわれたらいかがでしょう？。
ステロイド単剤と、合剤で比較をしたところ、ICS+LABAがもっとも反応性がよくICS+LTRAと比較して1.6倍、ICSと比較して1.1倍だったとの報告です。
気づき）
・フルチカゾン＋ロイコトリエン受容体拮抗剤（LTRA)がすでに発売？
・論文の結論にも書いてあるとおり、多くの小児はICS、LTRAだけで十分に反応していることを忘れずに！
・この論文、ちゃんと読んだ方がいいな
N Engl J Med. 2010 Mar 18;362(11):975-85. Epub 2010 Mar 2.
Step-up therapy for children with uncontrolled asthma receiving inhaled corticosteroids.
Background
For children who have uncontrolled asthma despite the use of low-dose inhaled corticosteroids (ICS), evidence to guide step-up therapy is lacking.
Methods
We randomly assigned 182 children (6 to 17 years of age), who had uncontrolled asthma while receiving 100μg of fluticasone twice daily, to receive each of three blinded step-up therapies in random order for 16 weeks: 250μg of fluticasone twice daily (ICS step-up), 100 µg of fluticasone plus 50μg of a long-acting beta-agonist twice daily (LABA step-up), or 100μg of fluticasone twice daily plus 5 or 10 mg of a leukotriene-receptor antagonist daily (LTRA step-up). We used a triple-crossover design and a composite of three outcomes (exacerbations, asthma-control days, and the forced expiratory volume in 1 second) to determine whether the frequency of a differential response to the step-up regimens was more than 25%.
Results
A differential response occurred in 161 of 165 patients who were evaluated (P<0.001). The response to LABA step-up therapy was most likely to be the best response, as compared with responses to LTRA step-up (relative probability, 1.6; 95% confidence interval [CI], 1.1 to 2.3; P=0.004) and ICS step-up (relative probability, 1.7; 95% CI, 1.2 to 2.4; P=0.002). Higher scores on the Asthma Control Test before randomization (indicating better control at baseline) predicted a better response to LABA step-up (P=0.009). White race predicted a better response to LABA step-up, whereas black patients were least likely to have a best response to LTRA step-up (P=0.005).
Conclusions
Nearly all the children had a differential response to each step-up therapy. LABA step-up was significantly more likely to provide the best response than either ICS or LTRA step-up. However, many children had a best response to ICS or LTRA step-up therapy, highlighting the need to regularly monitor and appropriately adjust each child’s asthma therapy. (ClinicalTrials.gov number, NCT00395304 [ClinicalTrials.gov] .)
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