asthma%20(pediatric)
ASTHMA (PEDIATRIC)

Asthma is a chronic inflammatory disease of the airways in the lungs of children and adults.
The patient usually complains of shortness of breath, chest tightness and coughing with wheezing.

A diagnosis of asthma in young children is more likely if they have symptom patterns, presence of risk factors for development of asthma and therapeutic response to controller treatment.
Goals of treatment are effective symptom control with minimal or no exacerbations, minimal or no nocturnal and daytime symptoms, no limitations on activities, minimal or no need for reliever treatment, and minimal adverse effects of medication.

Asthma%20(pediatric) Treatment

Initial Treatment of Asthma

  • After diagnosis of asthma is made, it is recommended to start corticosteroid (inhaled, low dose) as soon as possible for better outcomes
  • Depends on patient's presenting symptoms, risk factors, comorbidities and treatment preference

Recommended Options for Initial Treatment
Presenting Symptoms Children 6-11 years Adolescents
  • Symptoms occur <2x/month or not frequent
  • No risk factors for exacerbations
  • As-needed beta2-agonist (inhaled, short-acting)
  • Other options: Corticosteroid (inhaled) whenever beta2-agonist (inhaled, short-acting) is taken separately or in combination
  • As-needed corticosteroid (inhaled, low-dose) plus Formoterol
  • Other options: Corticosteroid (inhaled) whenever beta2-agonist (inhaled, short-acting) is taken separately or in combination
  • Presence of asthma symptoms ≥2x/month but <1x/day
  • Needs reliever medications
  • Corticosteroid (inhaled, low-dose) with as-needed beta2-agonist (inhaled, short-acting) or
  • Other options: Daily leukotriene modifier or corticosteroids (inhaled) whenever beta2-agonist (inhaled, short-acting) is taken separately or in combination
  • Corticosteroid (inhaled, low-dose) with as-needed beta2-agonist (inhaled, short-acting) or
  • As-needed corticosteroid (inhaled, low-dose) plus Formoterol
  • Other options: Daily leukotriene modifier or corticosteroids (inhaled) whenever beta2-agonist (inhaled, short-acting) is taken separately or in combination
  • Presence of troublesome asthma symptoms most days or waking due to symptoms ≥1x/week
  • Presence of risk factors for exacerbation
  • Corticosteroid (inhaled, low-dose) plus beta2-agonist (inhaled, long-acting) with as-needed beta2-agonist (inhaled, short-acting) or
  • Corticosteroid (inhaled, medium-dose) with as-needed beta2-agonist (inhaled, short-acting)
  • Other options: Corticosteroid (inhaled, low-dose) with daily leukotriene modifier and as-needed beta2-agonist (inhaled, short-acting)
  • Corticosteroid (inhaled, low-dose) plus beta2-agonist (inhaled, long-acting) as maintenance and reliever therapy with corticosteroid (inhaled) plus Formoterol or
  • Corticosteroid (inhaled, low-dose) plus beta2-agonist (inhaled, long-acting) as maintenance only with as-needed beta2-agonist (inhaled, short-acting) or
  • Corticosteroid (inhaled, medium-dose) with as-needed beta2-agonist (inhaled, short-acting)
  • Presence of severely uncontrolled asthma at initial presentation
  • Presence of acute exacerbation
  • Corticosteroids (inhaled, medium dose) plus beta2-agonist (inhaled, long-acting) with as-needed beta2-agonist (inhaled, short-acting)
  • Corticosteroids (oral) short course may be needed
  • Other options: Daily corticosteroids (inhaled, high-dose) plus beta2-agonist (inhaled, long-acting) or add-on Tiotropium or leukotriene modifier, with as-needed beta2-agonist (inhaled, short-acting)
  • Corticosteroids (inhaled, high-dose) or
  • Corticosteroids (inhaled, medium dose) plus beta2-agonist (inhaled, long-acting)
  • Corticosteroids (oral) short course may be needed
  • Modified from: Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2020.

    Principles of Therapy

    • Goals of long-term management of asthma includes:
      • Effective symptom control with minimal or no exacerbations
      • Minimal or no daytime and nocturnal symptoms
      • No limitations on activities, including exercise
      • Minimal or no need for reliever treatment
      • Normal or near normal pulmonary function
      • Minimal adverse effects of medication 
    • These are achieved through a cycle of:
      • Assess (diagnosis, symptom control, risk factors, inhaler technique, adherence, parent preference)
      • Adjust treatment (medications, non-pharmacological strategies, treatment of modifiable risk factors)
      • Review regularly response including medication effectiveness and side effects
    Management Plans for Long-Term Asthma Control:

     Recommended Medications Based on Level of Control
     Treatment Steps  Daily Controller Medications
    Children ≤5 years Children ≥6 years
    Step 1
    • No daily medication required

    Reliever

    • As needed beta2-agonist (inhaled, short-acting)
    • No daily medication required

    Preferred controller

    • As needed corticosteroid (inhaled, low-dose) plus Formoterol1,2

    Other controller options:

    • Corticosteroid (inhaled, low-dose) if taking beta2-agonist (inhaled, short-acting)1,3
    • Daily corticosteroid (inhaled, low-dose)

    Preferred reliever3

    • As needed corticosteroid (inhaled, low-dose) plus Formoterol2

    Other reliever option

    • As needed beta2-agonist (inhaled, short-acting)
    Step 2

    Preferred Controller 

    • Daily corticosteroid (inhaled, low-dose)

    Other controller options:

    • Daily leukotriene modifier
    • Intermittent corticosteroid (inhaled) 

    Reliever

    • As needed beta2-agonist (inhaled, short-acting)

    Preferred Controller  

    • Daily corticosteroid (inhaled, low-dose)
    • As needed corticosteroid (inhaled, low-dose) plus Formoterol1,2

    Other controller options (any of the following):

    • Leukotriene modifier 
    • Corticosteroid (inhaled, low-dose) if taking beta2-agonist (inhaled, short-acting)1,3
    • Daily corticosteroid (inhaled, low-dose) plus as-needed beta2-agonist (inhaled, short-acting)2

    Preferred reliever and other reliever option same as Step 1

    Step 3 Preferred Controller
    • Corticosteroid (inhaled, double low-dose)

    Other controller options:

    • Corticosteroid (inhaled, low-dose) plus leukotriene modifier5

    Reliever

    • As needed beta2-agonist (inhaled, short-acting)6

    Preferred Controller 

    • Corticosteroid (inhaled, low-dose) plus beta2-agonist (inhaled, long-acting)2
    • Corticosteroid (inhaled, medium-dose)4

    Other controller options (any one of the following):

    • Corticosteroid (inhaled, medium-dose)2
    • Corticosteroid (inhaled, low-dose) plus leukotriene modifier
    • House dust mite sublingual immunotherapy (SLIT)7

    Preferred reliever and other reliever option same as Step 18

    Step 4
    • Continue controller treatment
    • Specialist referral

    Other controller options

    • Any of the following 
      • Add leukotriene modifier
      • Increase corticosteroid (inhaled) frequency
      • Add intermittent corticosteroid (inhaled)

    Reliever

    • As needed beta2-agonist (short-acting) 

    Preferred Controller

    • Corticosteroid (inhaled, medium-dose) plus beta2-agonist (inhaled, long-acting)5

    Other controller options (any of the following):

    • Corticosteroid (inhaled, high-dose)
      • Plus beta2-agonist (inhaled, long-acting)4
    • Add-on Tiotropium bromide
    • Add-on leukotriene modifier
    • House dust mite SLIT7

    Preferred reliever and other reliever option same as Step 18

    Step 59 N/A

    Preferred Controller

    • Corticosteroid (inhaled, high-dose) plus beta2-agonist (inhaled, long-acting)2
    • Plus any of the following:
      • Tiotropium bromide
      • Anti-IgE (SC Omalizumab)
      • Anti-IL5 (SC Mepolizumab)
      • Anti-IL5 receptor (SC Benralizumab10)
      • Anti-IL4α receptor (SC Dupilumab10)

    Other controller options (any of the following):

    • Add-on corticosteroid (oral, low-dose)

    Preferred reliever and other reliever option same as Step 18

    Modified from: Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2020.
    1Used as off-label therapy.
    2Recommended option for patients ≥12 years of age.
    3Low-dose inhaled corticosteroids may be used separately or in combination with short-acting inhaled beta2-agonists.
    4Recommended option for patients 6-11 years of age.
    5Expert referral is recommended for patients 6-11 years old when asthma is not controlled despite treatment with moderate-dose inhaled corticosteroids.
    6Short-acting inhaled beta2-agonists should be used as required to relieve symptoms. Other options for reliever medications include anticholinergic (inhaled), beta2-agonists (oral, short-acting), or Theophylline (≥12 years old).
    7May be considered in sensitized patients ≥12 years of age with allergic rhinitis and FEV1 >70% predicted.
    8
    For patients previously given low-dose Budesonide/Formoterol or low-dose Beclomethasone dipropionate/Formoterol combination as maintenance and reliever regimen.
    9Refer patients for phenotypic assessment.
    10Contraindicated in patients <12 years of age.

     
     
     
     
     
     
     
     
                                               

    Maintaining Control of Asthma

    • Step-wise approach to therapy is the advancement to the next step of therapy if control is not reached or obtained with the current treatment
    • Treatment should be individualized based on the availability of antiasthmatic medications, resources of healthcare system, individual patient circumstances and cost
    Step Down
    • Once control is achieved and maintained for ≥3 months, gradual step-wise reduction in treatment may be attempted
    • Not applicable for patients at risk of exacerbations or persistent and fixed airflow limitation
    • Patients currently on inhaled corticosteroids:
      • Consider reducing dose by 25-50% at 2-3 months interval
      • If given with long-acting beta2-agonist and add-on agents, specialist referral is advised
    • Patients adequately controlled by low-dose inhaled corticosteroid or a leukotriene modifier:
      • Inhaled low-dose corticosteroids may be reduced to once-daily dosing
      • May shift to as-needed low-dose inhaled corticosteroid-Formoterol therapy
      • Addition of leukotriene modifiers may be considered when stepping down inhaled corticosteroids dose
      • Discontinuation of inhaled corticosteroid therapy in adolescents is not advised
    • In patients ≥12 years on inhaled corticosteroid-Formoterol combination therapy: Reduce maintenance inhaled corticosteroid-Formoterol therapy from medium-dose to low-dose or low-dose to once-daily dose and continue as-needed low-dose corticosteroid-Formoterol reliever regimen
    Step Up
    • Consider step-up if control is not maintained (review patient medication techniques, compliance and non-pharmacological control, comorbidities)
    • Sustained step-up of 2-3 months duration may be considered in patients who are not responding to initial treatment regimen despite good treatment adherence and removal of modifiable risk factors
    • Short-term step-up of 1-2 weeks involved increasing the dose of inhaled corticosteroid for 1-2 weeks for special situations such as in the presence of viral infections or seasonal allergens
    • Daily adjustment is needed for patients prescribed as-needed low-dose inhaled corticosteroid-Formoterol combination for mild asthma, or maintenance/reliever therapy using low-dose inhaled corticosteroid-Formoterol

    Pharmacotherapy

    Stepwise Therapy Based on Control

    Step 1 - Use of as-needed reliever

    • For children who have infrequent viral wheezing episodes and no or few interval symptoms, use of inhaled short-acting beta2-agonist is recommended for relief of symptoms
      • A need for a trial of controller medication is indicated if the child uses short-acting beta2-agonist for the relief of symptoms on average of >2x/week for over a month
    • Intermittent inhaled corticosteroids may be an option for children with intermittent viral-induced wheezing
    • Patient adherence to medication should be considered when prescribing corticosteroids

    Step 2 - Use of initial controller plus as-needed reliever 

    • For patients who require controller medications everyday in order to maintain control of their asthma
    • For children whose symptom pattern is consistent with asthma, and asthma symptoms are inadequately controlled or with ≥3 exacerbations/year
    • For children whose symptom pattern are inconsistent with asthma but with frequent wheezing episodes requiring reliever medication
    • May be used as initial therapy for treatment-naive patients ≤5 years old to control asthma symptoms
    • Low-dose daily inhaled corticosteroid is preferred for children ≤5 years old
      • As needed inhaled corticosteroids may be considered in pre-schoolers with increased frequency of wheezing secondary to viral infections after initial treatment with daily inhaled corticosteroids
    • It should be given for at least 3 months to achieve good asthma control
    • Leukotriene modifiers may reduce symptoms and oral corticosteroid use in pediatric patients with persistent asthma
    • Use of daily low-dose inhaled corticosteroid with long-acting beta2-agonist as initial maintenance controller treatment is an option for patients ≥12 years given controller medications for the first time

    Step 3 -Use of additional controller, plus as-needed reliever and expert referral

    • Before stepping up, re-confirm asthma diagnosis, check inhaler technique and compliance to medications and inquire about exposure to risk factors
    • For patients whom symptoms were not controlled by low-dose inhaled corticosteroids after 3 months of initial therapy or if exacerbations persisted
    • Medium-dose inhaled corticosteroid is preferred
    • Addition of oral leukotriene modifiers to low-dose corticosteroids may be considered
    • Addition of house dust mite SLIT may also be considered in patients ≥12 years of age sensitized to house dust mite with allergic rhinitis and FEV1 >70% predicted

    Step 4 -Daily controller and reliever therapy continued and expert referral

    • Reassess inhaler technique, medication adherence, trigger factors and reinvestigate diagnosis
    • If symptom control is still not achieved, may consider increasing the dose of inhaled corticosteroid until improvement is seen 
    • Consider expert referral if increasing the dose of inhaled corticosteroids fails or if symptom control remains poor and/or flare-ups persist
    • Add-on therapy with the following until symptom control is achieved: Oral leukotriene modifiers, long-acting inhaled beta2-agonist in combination with inhaled corticosteroid, Theophylline, or low-dose oral corticosteroid
      • May add intermittent inhaled corticosteroid to daily corticosteroid dose if main concern is exacerbation
      • Tiotropium by mist inhaler is only to be given to patients ≥6 years old with a history of exacerbations
      • Routine use of Theophylline as a controller is not recommended and may only be considered as an add-on therapy until asthma control is achieved if approved by a specialist
    • Addition of house dust mite SLIT may also be considered in patients ≥12 years of age sensitized to house dust mite with allergic rhinitis and FEV1 >70% predicted 
    • For patients ≥6 years old, being considered for high-dose inhaled corticosteroids, advise should be given about the increased risk for side effects and should be referred for expert assessment

    Step 5 -Add-on treatment and expert referral

    • For patients ≥6 years old, Step 5 is recommended if symptoms are not controlled by step 4 medications
    • Patient should be referred to a specialist for further diagnostic evaluation including assessment of phenotype and additional treatment
    • Addition of Tiotropium or a monoclonal antibody may be considered if symptoms are still not controlled
      • Tiotropium via mist inhaler may be considered for adolescent patients ≥6 years old with history of exacerbations despite combination therapy in Step 3
      • Addition of anti-IgE Omalizumab may be considered in pediatric patients ≥6 years of age diagnosed with moderate-severe asthma when control is not achieved despite combination treatments
      • Additional anti-IL-5 Mepolizumab may be considered for patients ≥6 years of age, and anti-IL5 receptor Benralizumab in patients ≥12 years of age with severe uncontrolled eosinophilic asthma despite adherence to step 4 regimen
      • Add-on anti-IL4α receptor subcutaneous Dupilumab in patients ≥12 years of age with severe type 2 asthma or those on maintenance oral corticosteroid

    Controller Medications

    Preferred Therapy

    • Corticosteroids (Inhaled)
      • These are the most effective anti-inflammatory medications used for asthma and are the preferred controller medications for patients with persistent asthma of all levels of severity
      • Discontinuation is followed by deterioration of control within weeks to months in some patients
      • To minimize side effects, upon achievement of control, corticosteroids should be titrated carefully to lowest effective dose to maintain control
        • Ciclesonide, a prodrug that is activated only in the lungs, may be an alternative with decreased oropharyngeal side effect
      • Combination with Formoterol as initial treatment is preferred over daily inhaled corticosteroids monotherapy due to issues with treatment adherence 
      • Addition of long-acting inhaled beta2-agonist is preferred when daily low-dose inhaled corticosteroid fails
        • Improves lung function and symptoms, reduces exacerbations, decreases need of short-acting beta2-agonists, achieves faster clinical control of asthma, and may also be used to prevent exercise-induced asthma

    Alternative or Add-On Therapy

    • Anticholinergic (Inhaled)
      • Eg Tiotropium bromide, Ipratropium bromide 
      • Considered alternative to short-acting inhaled beta2-agonists because they may have a slower onset of action and/or higher risk for side effects
      • Have an additive effect when nebulized together with a short-acting beta2-agonists for exacerbations of asthma
      • Considered in patients who experience adverse effects (eg tachycardia, arrhythmia, tremor) from short-acting beta2-agonists
      • May help improve lung function and decrease interval to next asthma exacerbation
      • Ipratropium bromide should only be considered for exacerbations and not for long-term therapy
    •  Beta2-Agonists (Inhaled, Long-acting)
      • Has no effect on airway inflammation, hence not used as a monotherapy
      • Most efficacious when given together with inhaled corticosteroids
        • Rapid clinical control of asthma is achieved than when inhaled glucocorticosteroids are given alone
        • Studies have shown increased mortality risk when given alone; should not be used as a substitute for corticosteroids
        • Causes improved symptom scores, decreased nocturnal asthma symptoms, improved lung function, decreased use of short-acting beta2-agonists, and reduced number of exacerbations
    • Beta2-Agonist (Oral, Long-acting)
      • May be considered as an alternative add-on therapy and should always be given with inhaled corticosteroids
      • Only used on rare occasions when more bronchodilation is needed
      • Less effective than inhaled beta2-agonists and poses increased risk of side effects
    • Corticosteroids (Oral)
      • Long-term use (>2 weeks) may be required for severely uncontrolled asthma
      • Long-term use should be used at the lowest possible dose
    • Cromones (Inhaled)
      • Limited use in long-term treatment of asthma
      • May be used for patients with mild persistent asthma and exercise-induced bronchoconstriction
      • Weak anti-inflammatory effect, less effective than low-dose inhaled corticosteroids
    • Leukotriene Modifiers (Oral)
      • When used as add-on therapy, may reduce the required dose of inhaled corticosteroid for patients with moderate to severe symptoms
        • When used as monotherapy for control of asthma, leukotriene modifiers are less effective than low-dose inhaled corticosteroids 
    • Monoclonal Antibodies (eg Benralizumab, Dupilumab, Mepolizumab, Omalizumab)
      • Treatment option for patients ≥12 years of age 
      • Reduces asthma symptoms and exacerbations, and the need for rescue medications
      • Omalizumab is indicated for patients ≥6 years old with moderate to severe asthma with allergic component not controlled by inhaled corticosteroids
      • For patients with severe eosinophilic asthma not controlled by inhaled corticosteroids, Mepolizumab may be considered in patients ≥6 years of age and Benralizumab in patients ≥12 years of age
      • Add-on Dupilumab may be considered in patients ≥12 years old with severe asthma and atopic dermatitis
      • Use of Reslizumab in patients <18 years of age with asthma has not been established
    • Theophylline (Oral, Extended-Release)
      • Treatment option for patients >12 years of age
      • Bronchodilator, which at low dose, has anti-inflammatory effects

    Reliever Medications

    Preferred Therapy

    • Beta2-Agonists (Inhaled, Short-Acting)
      • Preferred reliever for patients <12 years of age; alternative reliever to inhaled corticosteroid-Formoterol combination in patients ≥12 years of age 
      • Most effective bronchodilator
      • Agents of choice for relief of bronchoconstriction during acute episodes of asthma and are useful for pre-treatment prior to exercise with effects lasting for 0.5 to 2 hours
      • Used only when necessary; increased use indicates that management should be re-assessed
        • Concomitant use with corticosteroid is recommended with every intake of a short-acting inhaled beta2-agonist to prevent side effects of short-acting inhaled beta2-agonist monotherapy
    • Corticosteroids (Inhaled) with Formoterol
      • Preferred reliever for patients ≥12 years of age
      • Combination of steroid with Formoterol is preferred for patients previously given Budesonide-Formoterol or Beclometasone-Formoterol maintenance and reliever therapy
      • Reliever-only initial treatment ie as-needed short-acting inhaled beta2-agonist is no longer recommended  due to accumulated reports of increased risk of exacerbations and lower lung function with short-acting inhaled beta2-agonist monotherapy

    Alternative Therapy

    • Beta2-Agonists (Oral, Short-Acting)
      • Reserved for children in whom inhaled therapy is not well-tolerated
      • More side effects than inhalation route

    Allergen-Specific Immunotherapy

    • Therapeutic option after strict avoidance of triggers and medical intervention have failed
    • May be given as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT)
      • Life-threatening anaphylactic reactions have been reported with SCIT use
      • SLIT has been associated with mild oral and gastrointestinal (GI) symptoms
    • May reduce symptoms, medication use, improve allergen-specific and non-specific airway hyperresponsiveness and can possibly prevent asthma development in children with allergic rhinoconjunctivitis
    • Benefits must be weighed against adverse effects and inconvenience of length of therapy
    • Efficacy of extracts or regimens based on clinical trials should be put into consideration before initiating therapy

    Difficult-to-treat Asthma

    • Defined as asthma with persistent symptoms and/or exacerbations despite adherence to high-dose asthma regimens (eg Step 4-5 of the management plan for long-term asthma, high-dose inhaled corticosteroids in adults or medium-dose inhaled corticosteroids in children with a long-acting inhaled beta2-agonist or leukotriene modifier, continuous/frequent therapy with oral corticosteroids)
    • Risk factors include: Incorrect inhaler technique, poor adherence, comorbidities, exacerbation triggers, over-use of a long-acting inhaled beta2-agonist, psychosocial factors, adverse effects of medications
    • Steps to optimize management:
      • Check, review, correct and demonstrate inhaler technique every visit
      • Confirm if patient has a written asthma action plan and confirm if the patient understands what is included
      • Treat comorbidities and modifiable risk factors
      • Consider lifestyle modifications, avoidance of triggers and other non-pharmacologic treatments
      • Consider the following if not previously given: Nonbiologic therapies (eg Tiotropium bromide, Azithromycin, long-acting beta2-agonist), biologic therapies (eg Mepolizumab, Dupilumab, Benralizumab, etc), high-dose inhaled corticosteroids
    • Advise patient to follow-up after 3-6 months to assess patient's response to treatment changes
      • Referral to a specialist or to a severe asthma clinic is recommended if asthma is still with uncontrolled even with modifications and optimization of treatment
      • If with uncontrolled symptoms and/or exacerbations after treatment step-down, return previous regimen and refer to a specialist or to a severe asthma clinic
    • Assess patient's inflammatory phenotype and considered add-on biologic treatments once identified
      • Review patient response after 3-4 months

    Preferred Inhalation Devices

    PREFERRED INHALATION DEVICES 
     Age  Device
     0-3 years Preferred: Pressurized metered-dose inhaler plus dedicated spacer with face mask
    Alternate: Nebulizer with face mask
     4-5 years Preferred: Pressurized metered-dose inhaler plus dedicated spacer with mouthpiece
    Alternate: Pressurized metered-dose inhaler plus dedicated spacer with face mask or nebulizer with mouthpiece or face mask
    Modified from: Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2020. p154.

    Treatment of Acute Exacerbations in Primary Care

    • Treatment of patients with mild/moderate asthma exacerbation and PEF >50% predicted/best:
      • Salbutamol 2-10 puffs depending on age every 20 minutes for 1 hour
      • Consider Prednisolone
      • Administer O2
    • Treatment of patients with severe/life-threatening asthma exacerbation and PEF <50% predicted/best:
      • Transport to emergency department
      • While waiting, administer:
        • Salbutamol 6-10 puffs every 20 minutes as needed
        • O2 therapy 
        • Oral/IV Prednisolone
        • Ipratropium bromide
    • Dose of Salbutamol should be based on patient's age:
      • ≥6 years old: 4-10 puffs by pMDI with spacer and mask or mouthpiece
      • ≤5 years old: 2 puffs (100 mcg/puff) by pMDI with spacer and mask or mouthpiece, or 2.5 mg by air-driven nebulizer or oxygen-driven nebulizer if with low SaO2
        • If unresponsive to initial dose after 1 hour, may give 2-6 more puffs 20 minutes after the 1st dose and may repeat at 20-minute intervals for 1 hour
    • In patients with poor response or worsening condition after 1st-line treatment, continue therapy while arranging hospital admission
    • Oral Prednisone/Prednisolone may be considered with dose of 1-2 mg/kg/day for 1-5 days up to maximum dose of 20 mg/day for 0-2 years old and 30 mg/day for 3-5 years old or Dexamethasone 0.6 mg/kg/day for 2 days

    Dosage Guidelines

    ANTICHOLINERGICS (INHALED)1
    Drug Available Strength Dosage Remarks
    Long-Acting Adverse Reactions
    • Resp effects [upper respiratory tract infection (URTI), bronchitis, sinusitis]; CV effects (chest pain, palpitation); CNS effects (headache, dizziness); GI effects (dry mouth, bad taste, dyspepsia, nausea); Hypersensitivity reactions (urticaria, angioedema, rash, bronchospasm)
    Special Instructions
    • Use with caution in patients with prostatic hyperplasia, patients predisposed to narrow-angle glaucoma, bladder neck obstruction, myasthenia gravis
    • Avoid contact of eyes with inhalation solution
    • Check patient's inhaler technique for optimum delivery of drug
    • Not used as 1st-line treatment
      • Should be added to beta2-agonist therapy
    Tiotropium bromide 1.25 mcg/puff ≥6 yr: 2 puffs 24 hrly
    Short-Acting
    Ipratropium bromide 20 mcg/puff MDI 2 puffs 6 hrly
    Max dose: 12 puffs/day
    250 mcg/2 mL & 500 mcg/2 mL inhalation soln unit dose 1 unit dose (250-500 mcg) via nebulizer 6-8 hrly as required
    0.025% inhalation soln <6 yr: 0.4-1 mL (100-250 mcg) via nebulizer 6-8 hrly as required
    6-12 yr: 1 mL (250 mcg) via nebulizer 6-8 hrly as required
    1Bronchodilator combinations are available. Please see the latest MIMS for specific formulations.


    BETA2-AGONISTS (BRONCHODILATORS) (INHALED)1
    Drug Available Strength Dosage* Remarks
    Short-Acting
    Fenoterol 100 & 200 mcg/puff MDI Approved in some countries for childn >6 yr: 1-2 puff 8 hrly as required Adverse Reactions
    • CV effects (tachycardia, palpitations, cardiac arrhythmias especially in susceptible patients); CNS effects (headache, hyperactivity); Resp effects (mouth and throat irritation, paradoxical bronchospasm); Other effect (fine skeletal muscle tremor)
    • Potentially severe hypokalemia may result especially in acute severe asthma
    • Orciprenaline is less selective for beta2-receptors and therefore, side effects may be more common
    Special Instructions
    • Use with caution in patients with hyperthyroidism, DM, myocardial insufficiency or arrhythmias
    • Monitor K levels in acute severe asthma
    • Check patient's inhaler technique for optimum delivery of drug
    1.25 mg/2 mL soln for inhalation 10-20 drops via nebulizer up to 6 hrly as required
    6-14 yr: 10 drops 8 hrly
    1-6 yr: 5-10 drops 8 hrly
    <1 yr: 3-7 drops 8 hrly
    Orciprenaline (Metaproterenol) 750 mcg/puff MDI 1-2 puffs 8 hrly as required
    Max dose: 12 puffs/day
    Procaterol 10 mcg/puff MDI Approved in some countries for childn: 1 puff 6-12 hrly as required
    Salbutamol (Albuterol) 100 mcg/dose (autohaler/evohaler) Immediate relief/prior to exertion: 100 mcg as single dose
    For chronic or preventive treatment: 100 mcg 6-8 hrly
    May increase to 200 mcg 6-8 hrly if necessary
    Max dose: 1.2 mg/day
    100 & 200 mcg/dose easyhaler
    100 mcg/dose MDI
    100 & 200 mcg/dose DPI
    200 mcg/dose accuhaler DPI
    200 mcg/dose diskhaler DPI
    200 mcg/cap DPI
    1 mg/mL, 2.5 mg/2.5 mL, 5 mg/2.5 mL inhalation soln unit dose 2.5-5 mg via nebulizer 6-8 hrly as required
    5 mg/mL (0.5% soln) inhalation soln 10-15 kg: 0.25 mL (1.25 mg)
    >15 kg: 0.5 mL (2.5 mg)
    >12 yr: 0.5-1 mL (2.5-5 mg)
    Dilute required amount of solution with normal saline to final volume of 2-3 mL via nebulizer over 10 min as required
    Terbutaline 250 mcg/puff MDI 1-2 puffs 6-8 hrly as required
    Max dose: 8 puffs/day
    500 mcg/dose DPI, turbuhaler DPI 3-12 yr: 1 dose inhaled 6 hrly as required
    For severe exacerbations: 2 doses
    Max dose: 8 doses/day
    2.5 mg/2 mL, 5 mg/2 mL inhalation soln <20 kg: 2.5 mg via nebulizer up to 6 hrly as required
    >20 kg: 5 mg via nebulizer up to 6 hrly as required
    Long-Acting2
    Formoterol 4.5 mcg/dose turbuhaler DPI Approved in some countries for childn ≥6 yr: 1-2 doses inhaled 12-24 hrly
    Max dose: 4 doses/day
    Adverse Reactions
    • CV effects (tachycardia, palpitations, cardiac arrhythmias especially in susceptible patients); CNS effects (headache, hyperactivity); Resp effects (mouth and throat irritation, paradoxical bronchospasm); Other effect (fine skeletal muscle tremor)
    • Potentially severe hypokalemia may result especially in acute severe asthma
    Special Instructions
    • Use with caution in patients with hyperthyroidism, DM, myocardial insufficiency or arrhythmias
    • Monitor K levels in acute severe asthma
    • Check patient's inhaler technique for optimum delivery of drug
    9 mcg/dose turbuhaler DPI Approved in some countries for childn ≥6 yr: 1 dose inhaled 12-24 hrly
    Max dose: 2 doses/day
    12 mcg/cap DPI Approved in some countries for childn ≥5 yr: 1 cap inhaled 12 hrly
    Salmeterol 25 mcg/puff MDI ≥4 yr: 2 puffs 12 hrly
    50 mcg/dose accuhaler DPI, diskhaler DPI ≥4 yr: 1 dose inhaled 12 hrly
    *Please note: Doses for acute exacerbations can be higher than the recommended maintenance doses listed here.
    1Inhaled bronchodilator combinations are available. Please see the latest MIMS for specific formulations.
    2Should be used as an adjunct to inhaled corticosteroids in the management of asthma. Please see the latest MIMS for specific formulations of different combination products.


    BETA2-AGONISTS (BRONCHODILATORS) (ORAL)1
    Drug Dosage Remarks
    Short-Acting Adverse Reactions
    • CNS effects (headache, sleep disturbances, agitation, hyperactivity and restlessness); CV effects (palpitations, cardiac arrhythmias especially in susceptible patients); Other effect (fine skeletal muscle tremor)
    • Potentially severe hypokalemia may result especially in acute severe asthma
    • Orciprenaline is less selective for beta2 receptors and therefore side effects may be more common
    Special Instructions
    • Use with caution in patients with hyperthyroidism, DM, myocardial insufficiency or arrhythmias
    • Monitor K levels in acute severe asthma
    Clenbuterol 1.2 mcg/kg/day PO divided 12 hrly
    Fenoterol Approved for use in some countries for childn:
    <1 yr:
    1.25 mg PO 8-12 hrly
    1-6 yr: 1.25-2.5 mg PO 8 hrly
    6-14 yr: 2.5 mg PO 8 hrly
    Hexoprenaline Approved for use in some countries for childn:
    3-6 mth:
    0.125 mg PO 12-24 hrly
    6-12 mth: 0.125 mg PO 8-24 hrly
    1-3 yr: 0.125-0.25 mg PO 8-24 hrly
    3-6 yr: 0.25 mg PO 8-24 hrly
    6-10 yr: 0.5 mg PO 8-24 hrly
    Orciprenaline (Metaproterenol) 3-10 yr: 10 mg PO 6 hrly
    Procaterol <6 yr: 1.25 mcg/kg/dose PO 12 hrly
    >6 yr: 25 mcg PO 12-24 hrly
    Salbutamol2 (Albuterol) 2-6 yr: 1-2 mg PO 6-8 hrly
    Max dose: 12 mg/day
    6-12 yr: 2 mg PO 6-8 hrly
    Max dose: 24 mg/day
    >12 yr: 2-4 mg PO 6-8 hrly
    Max dose: 32 mg/day
    Terbutaline <12 yr: 0.05 mg/kg/dose PO 8 hrly
    Max dose: 5 mg/day
    ≥12 yr: 2.5-5 mg PO 8 hrly
    Max dose: 15 mg/day
    Long-Acting
    Bambuterol Approved for use in some countries for childn 2-12 yr: 5-10 mg PO 24 hrly
    Max dose for childn 2-5 yr: 10 mg/day (Doses >10 mg/day PO is not recommended in Asian childn 2-12 yr)
    Formoterol 4 mcg/kg/day PO divided 8-12 hrly
    Salbutamol (Albuterol) Extended-release:
    <12 yr: 0.3-0.6 mg/kg/day divided 12 hrly
    >12 yr: 4 mg PO 12 hrly
    1Oral bronchodilator combinations are available. Please see the latest MIMS for specific formulations.
    2Combination with other cough preparation is available. Please see the latest MIMS for specific formulations.


    BRONCHODILATORS (PARENTERAL)
    Drug Dosage Remarks
    Beta2-Agonists
    Hexoprenaline 5-10 mcg slow IV inj x 3-4 doses in 24 hr Adverse Reactions
    • Fine skeletal muscle tremor, palpitations, cardiac arrhythmias especially in susceptible patients, headache, sleep disturbances, agitation, hyperactivity and restlessness
    • Potentially severe hypokalemia may result especially in acute severe asthma
    • Epinephrine: Dyspnea, hyperglycemia, restlessness, palpitations, tachycardia, tremors, sweating, hypersalivation, weakness, dizziness, headache, coldness of extremities, hypertension, flushing, hypotension
    Special Instructions
    • Use with caution in patients with hyperthyroidism, DM, myocardial insufficiency or arrhythmias
    • Monitor K levels in acute severe asthma
    Salbutamol 250 mcg slow IV inj, may repeat as required
    500 mcg IM/SC, may repeat 4 hrly as required
    IV infusion: 3-20 mcg/min IV infusion
    Terbutaline 2-15 yr: 10 mcg/kg/dose SC/slow IV up to 6 hrly as required
    Max dose: 300 mcg/dose
    IV infusion: 25 mcg/kg/day IV as a continuous infusion
    Nonspecific Sympathomimetic
    Epinephrine (Adrenaline) 10 mcg/kg up to 300-500 mcg SC/IM every 20 min x 3 doses


    CORTICOSTEROIDS (INHALED)1
    Drug Available Strength Dosage Remarks
    Beclomethasone dipropionate  50, 100, 250 mcg/puff MDI

    Childn <5 yr:
    HFA-based
    Low dose: 100 mcg2
    Medium dose: >200-400 mcg

    Childn 6-11 yr:
    CFC-based
    Low dose: 100-200 mcg
    Medium dose: >200-400 mcg
    High dose: >400 mcg

    HFA-based
    Low dose: 50-100 mcg
    Medium dose: >100-200 mcg
    High dose: >200 mcg

    Childn >12 yr:
    CFC-based
    Low dose: 200-500 mcg
    Medium dose: >500-1000 mcg
    High dose: >1000 mcg

    HFA-based
    Low dose: 100-200 mcg
    Medium dose: >200-400 mcg
    High dose: >400 mcg

    Adverse Reactions
    • Local effects (oropharyngeal candidiasis, cough from upper airway irritation, dysphonia); paradoxical bronchospasm (rare)
    • Long-term use of high-dose steroids may result in cataracts, glaucoma, skin thinning, easy bruising, adrenal suppression, increased bone loss and osteoporotic fractures
    • Risk of systemic effects will depend on dose, potency of the corticosteroid, absorption from the gut, delivery system, the use of spacers and the drug’s pharmacokinetics
    Special Instructions
    • Local effects may be minimized by using a spacer, gargling and spitting out with water, or gargling with 1:50 dilution of Amphotericin B
    100, 200 mcg/cap DPI; 100, 200 mcg/dose diskhaler DPI;
    200 mcg/dose easyhaler DPI
    Budesonide 100, 200 mcg/puff MDI

    Childn <5 yr:
    Low dose: 200 mcg
    Medium dose: >200-400 mcg

    Nebules
    Low dose: 500 mcg3
    Medium dose: >500-1000 mcg
    High dose: >1000 mcg

    Childn 6-11 yr:
    Low dose: 100-200 mcg
    Medium dose: >200-400 mcg
    High dose: >400 mcg

    Nebules
    Low dose: 250-500 mcg
    Medium dose: >500-1000 mcg
    High dose: >1000 mcg

    Childn >12 yr:
    Low dose: 200-400 mcg
    Medium dose: >400-800 mcg
    High dose: >800 mcg

    100, 200, 400 mcg/dose turbuhaler DPI; 200 mcg/dose swinghaler;
    200 mcg/dose easyhaler;
    100, 200, 400 mcg/cap DPI
    250 mcg/2 mL, 500 mcg/2 mL, 500 mcg/mL, 1 mg/2 mL soln for inhalation unit dose
    Ciclesonide 80, 160 mcg/actuation MDI

    Childn <5 yr:
    Low dose: 160 mcg
    Medium dose: >160-320 mcg
    Once-daily dosing in patients with mild severity of asthma

    Childn 6-11 yr:
    Low dose: 80 mcg
    Medium dose: >80-160 mcg
    High dose: >160 mcg

    Childn >12 yr:
    Low dose: 80-160 mcg
    Medium dose: >160-320 mcg
    High dose: >320 mcg

    Fluticasone furoate 50, 100, 250 mcg/dose accuhaler DPI;
    50, 250 mcg dose diskhaler DPI;
    50, 125, 250 mcg/dose evohaler
    Childn >12 yr:
    Low dose: 100 mcg
    High dose: 200 mcg
    Fluticasone propionate 50, 125, 250 mcg/puff MDI

    Childn <5 yr:
    Low dose: 50 mcg4 
    Medium dose: >200-500 mcg
    High dose: >500 mcg


    Childn 6-11 yr:
    Low dose: 50-100 mcg 
    Medium dose: 100-200 mcg
    High dose: >200 mcg

    Childn >12 yr:
    Low dose: 100-250 mcg 
    Medium dose: >250-500 mcg 
    High dose: >500 mcg

    50, 125, 250 mcg/dose evohaler
    0.5 mg/2 mL, 2 mg/2 mL soln for inhalation unit dose
    Mometasone furoate 50, 100, 200 mcg/dose for inhalation unit dose

    Childn <5 yr:
    Low dose:
     100 mcg4 

    Childn 6-11 yr:

    Low dose: 100 mcg 
    Medium dose: 100 mcg
    High dose: 200 mcg

    Childn >12 yr:
    Low dose: 200-400 mcg
    Medium dose: 200-400 mcg
    High dose: >400 mcg

    Triamcinolone acetonide 75, 200 mcg/dose for inhalation unit dose

    Childn 6-11 yr:
    Low dose: 400-800 mcg
    Medium dose: >800-1200 mcg
    High dose: >1200 mcg

    Childn >12 yr:
    Low dose: 400-1000 mcg
    Medium dose: >1000-2000 mcg
    High dose: >2000 mcg

    1Corticosteroids combined with bronchodilators are available. Please see the latest MIMS for specific formulations.
    2Ages ≥5 years
    3Ages ≥1 year
    4Ages ≥4 years
    Modified from: Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2020. p56,153; British Thoracic Society Updated 2019. p73.


    CORTICOSTEROIDS (SYSTEMIC)
    Drug Dosage Remarks
    Dexamethasone Childn: 0.08-0.3 mg/kg/day IV/IM, divided 6-12 hrly
    Adverse Reactions
    • CNS effects (excessive mental stimulation, insomnia and psychic disturbances); CV effect (tachycardia); Other effects (increased appetite, weight gain, muscle weakness)
    Hydrocortisone Asthma exacerbations in emergency dept:
    2-4 mg/kg/dose slow IV/IV infusion 6 hrly x 24 hr
    Adjust dose according to response and reduce over 4-5 days to oral dose when tolerated
    Adverse Reactions
    • GI effect (gastritis). If administered long-term: Adrenocortical insufficiency, osteoporosis, muscle wasting, pain or weakness, increased susceptibility to infection, impaired wound healing, electrolyte imbalances, weight gain, DM, skin thinning leading to striae and easy bruising, cataracts, glaucoma
    Special Instructions
    • Should be taken with food
    • Patients on long-term corticosteroids should receive preventive treatment for osteoporosis
    Methylprednisolone, Prednisolone, Prednisone 1-2 mg/kg/day PO divided 6-8 hrly x 3-10 days
    Max dose: 60 mg/day


    COUGH AND COLD PREPARATIONS
    Drug Dosage Remarks
    Ambroxol ≤6 mth: 1.25 mL PO 12 hrly
    7 mth-2 yr: 2.5 mL PO 12 hrly
    2-6 yr: 2.5 mL PO 8 hrly
    7-12 yr: 5 mL PO 8-12 hrly
    Adverse Reactions
    • GI effects (N/V, diarrhea); Other effects (headache, polyuria, fatigue)
    Special Instruction
    • Should not be taken in an empty stomach
    • Use with caution in patients with gastric ulcer
    Bromhexine <5 yr: 2 mg PO 8 hrly
    5-10 yr: 4 mg PO 8 hrly
    >10 yr: 8 mg PO 8 hrly
    Adverse Reactions
    • GI effect (GI irritation); Metabolic effect (transient increase of serum transaminases)
    Special Instruction
    • Use with caution in patients with gastric ulcer
    Carbocisteine (Carbocysteine) Syr
    <2 yr:
     50 mg PO 12-24 hrly
    2-5 yr: 100-250 mg PO 12-24 hrly 
    5-12 yr: Up to 250 mg PO 8 hrly
    Tab
    6-12 yr: 375 mg PO 8 hrly
    Adverse Reactions
    • GI effects (GI disturbances, N/V); Hypersensitivity reactions (bronchospasm, rashes); Other effect (hypotension)
    Special Instruction
    • Use with caution in patients with gastric or duodenal ulcer
    Dried ivy leaf extract Syr
    1-5 yr: 2.5 mL PO 8 hrly
    6-10 yr:
    5 mL PO 8 hrly
    Effervescent Tab
    6-12 yr: 32.5 mg PO 12 hrly
    Adverse Reactions
    • Rarely, laxative effect due to sorbitol content
    Special Instructions
    • Use with caution in patients with fructose/sorbitol intolerance
    Guaifenesin Infant: 25 mg PO 6 hrly
    2-6 yr: 10-50 mg PO 4-6 hrly
    ≥7 yr: 20-100 mg PO 4-6 hrly
    Max Dose ≥6 yr: 600 mg/day
    Adverse Reactions
    • GI effects (GI discomfort, N/V); CNS effects (drowsiness, headache)
    Special Instruction
    • Use with caution in children <2 years old and in patients with persistent or chronic cough
    Lagundi (Vitex negundo) 15 mg/kg PO 8 hrly Adverse Reactions
    • GI effects (N/V, diarrhea); Dermatologic effect (rash)
    Special Instruction
    • Use with caution in patients with hypersensitivity to Lagundi


    CROMONE (INHALED)
    Drug Available Strength Dosage Remarks
    Cromoglicic acid (Cromolyn Na, Na cromoglicate, Na cromoglycate) 5 mg/puff MDI 2 puffs 6 hrly
    May increase to 2 puffs 6-8x/day in more severe cases and reduce to 1 puff 6 hrly once asthma has been stabilized
    Adverse Reactions
    • Resp effects (transient bronchospasm, cough and irritation of throat, rarely, severe bronchospasm, angioedema, laryngeal edema and anaphylaxis); Other effects (unpleasant taste, nausea, headache)
    Special Instructions
    • Should not be used for acute asthma attacks


    LEUKOTRIENE MODIFIERS (ORAL)
    Drug Dosage Remarks
    5-Lipoxygenase
    Zileuton ≥12 yr: 600 mg PO 6 hrly
    Extended-release:
    1.2 g PO 12 hrly
    Adverse Reactions
    • CNS effect (headache); GI effects (GI upset, raised liver enzymes); Other effects (rashes, leukopenia has occurred in a few patients)
    Special Instructions
    • Avoid in patients with hepatic impairment/disease
    • Monitor liver enzymes before and periodically during therapy
    • Should not be used for acute asthma attacks,
    Leukotriene Receptor Antagonists
    Montelukast 6 mth-5 yr: 4 mg PO 24 hrly before bedtime
    6-14 yr: 5 mg PO 24 hrly before bedtime
    ≥15 yr: 10 mg PO 24 hrly before bedtime
    Adverse Reactions
    • Generally well-tolerated: Headache, GI upset
    • Less commonly: Generalized pain, arthralgia, myalgia, fever, dizziness; hypersensitivity reactions
    • Zafirlukast: Raised liver enzymes, rarely symptomatic hepatitis, hyperbilirubinemia
    • Very rarely: Agranulocytosis, bleeding, bruising and edema, systemic eosinophilia consistent with Churg-Strauss disease
    Special Instructions
    • Should not be used for acute asthma attacks
    • Zafirlukast: Avoid in patients with hepatic impairment or cirrhosis
    Pranlukast 3.5 mg/kg PO 12 hrly
    Max dose: 10 mg/kg/day
    Zafirlukast 5-11 yr: 10 mg PO 12 hrly
    ≥12 yr: 20 mg PO 12 hrly


    MAST CELL STABILIZER/ANTIHISTAMINE (ORAL)
    Drug Dosage Remarks
    Ketotifen 6 mth-3 yr: 0.5 mg PO 12 hrly
    >3 yr: 1 mg PO 12 hrly
    Extended-release:
    >3 yr: 2 mg PO at bedtime
    Adverse Reactions
    • CNS effects (drowsiness, dizziness, CNS stimulation); GI effects (dry mouth, increased appetite, weight gain)
    Special Instructions
    • Should not be used for acute asthma attacks


    METHYLXANTHINES (ORAL)
    Drug Dosage Remarks
    Acefylline 500 mg-2 g/day PO in divided doses Adverse Reactions
    • GI effects (irritation, N/V, abdominal pain, diarrhea, gastroesophageal reflux); CNS effects (CNS stimulation, headache, anxiety, restlessness, dizziness, tremor); Other effect (palpitations)
    • Serum concentration >15-20 mcg/mL (85-110 micromol/L) are associated with increased risk of adverse effects including lethal adverse reactions
    Special Instructions
    • Use with caution in patients with peptic ulcer, hyperthyroidism, hypertension, cardiac arrhythmias or other CV disease, epilepsy, heart failure, hepatic dysfunction, acute febrile illness, in neonates
    • Many drug interactions occur with Theophylline including smoking
      • Increases Theophylline clearance
    • Serum concentration monitoring is necessary to ensure that concentration are within therapeutic range
      • Serum concentration needs to be measured if a patient is changed from one extended-release product to another
    • Optimal therapeutic concentration: 5-15 mcg/mL (28-85 micromol/L)
    Aminophylline Dosage should be individualized
    Choline theophyllinate 100 mg PO 6-8 hrly
    Diprophylline (Dyphylline) 15 mg/kg/dose PO 6 hrly
    Doxofylline <12 yr: 6-9 mg/kg/dose PO 12 hrly
    >12 yr: 200 mg PO 8-24 hrly
    Heptaminol acefyllinate >15 yr: 500 mg-1 g PO 8 hrly
    Theophylline1 Acute bronchospasm:
    Loading dose in patients not taking methylxanthine:
    5 mg/kg PO
    Maintenance dose:
    6 mth-<1 yr: 12-18 mg/kg/day PO
    1-<9 yr: 20-24 mg/kg/day PO
    9-<12 yr (including adolescent smokers): 16 mg/kg/day PO
    12-16 yr (nonsmokers): 13 mg/kg/day PO
    1Different formulations for Theophylline are available. Please see the latest MIMS for specific formulations.


    METHYLXANTHINES (PARENTERAL)
    Drug Dosage Remarks
    Acefylline 1.5-2 g/day IM
    0.5-1 g/day IV
    Adverse Reactions
    • GI effects (irritation, N/V, abdominal pain, diarrhea, gastroesophageal reflux); CNS effects (CNS stimulation, headache, anxiety, restlessness, dizziness, tremor); Other effect (palpitations)
    • Serum concentration >15-20 mcg/mL (85-110 µmol/L) are associated with increased risk of adverse effects including lethal adverse reactions
    Special Instructions
    • Administer IV inj very slowly to prevent dangerous CNS and CV side effects
    • Use with caution in patients with peptic ulcer, porphyria, hyperthyroidism, hypertension, cardiac arrhythmias or other CV disease, epilepsy, heart failure, hepatic dysfunction, acute febrile illness, in neonates
    • Serum concentration monitoring is necessary to ensure concentration are within therapeutic range
    • Optimal therapeutic concentration: 5-15 mcg/mL (28-85 µmol/L)
    Aminophylline Loading dose: 5 mg/kg IV infusion over 20-30 min
    Maintenance dose:
    6 mth-9 yr: 1 mg/kg/hr
    10-16 yr: 0.8 mg/kg/hr
    Proxyphylline 400-800 mg IM or slow IV 8 hrly


    MONOCLONAL ANTIBODIES
    Drug Dosage Remarks
    Anti-Immunoglobulin E (Anti-IgE) Antibody
    Omalizumab 6-11 yr: 75-375 mg in 1-3 SC inj every 2 or 4 wk
    ≥12 yr: 150-375 mg SC every 2 or 4 wk
    Dose depends on pretreatment IgE level and body weight
    Adverse Reactions
    • CNS effect (headache); Resp effects (resp infections, sinusitis, pharyngitis); Other effects (local site reaction, viral infection, anaphylaxis, malignancies)

    Special Instructions

    • Max of 150 mg should be delivered per inj site
    • Should not be used for the treatment of acute bronchospasm or status asthmaticus
    • Contraindicated in patients with severe hypersensitivity to the drug and in children <6 years old
    • Corticosteroids should be tapered gradually
    • Use with caution in patients at risk of parasitic infections
    Interleukin Inhibitors
    Benralizumab ≥12 yr: 30 mg SC every 4 wk x 3 doses, then every 8 wk Adverse Reactions
    • CNS effect (headache); Resp effects (cough, pharyngitis); Dermatologic effects (urticaria, rash, inj site reaction, erythema, pruritus, papule)
    Special Instructions
    • Not for acute asthma treatment
    • Use with caution in patients with helminth infection, children <12 years old, abrupt steroid withdrawal
    • Monitor for hypersensitivity reaction
    Dupilumab ≥12 yr:
    Initial dose: (200 mg x 2 doses) SC followed by 200 mg SC every other week or 600 mg (300 mg x 2 doses) SC followed by 300 mg SC given every other week
    Adverse Reactions
    • Inj site reaction, eosinophilia, oropharyngeal pain
    Special Instructions
    • Not for acute asthma treatment
    • Use with caution in patients with uncontrolled worsening asthma, helminth infection, children <12 years old, abrupt steroid withdrawal
    • Monitor for hypersensitivity reaction
    • Administer each of the 2 doses into different inj sites
    Mepolizumab 6-12 yr: 40 mg SC 24 hrly every 4 wk
    ≥12 yr:
    100 mg SC 24 hrly every 4 wk
    Adverse Reactions
    • Dermatologic effects (pruritus, eczema, inj site reaction including erythema, swelling, itching, burning); Musculoskeletal effects (muscle spasm, back pain); Resp effects (nasal congestion, dyspnea, allergic rhinitis, bronchospasm); Misc effects (UTI, headache, toothache, infection)
    Special Instructions
    • Not for acute asthma treatment
    • Use with caution in patients with uncontrolled worsening asthma, helminth infection, abrupt steroid withdrawal


    OTHER DRUGS ACTING ON THE RESPIRATORY SYSTEM
    Drug Dosage Remarks
    Bacterial lysate (Lyophilized H. influenzae, D. pneumoniae, K. pneumoniae, K. ozaneae, S. aureus, S. pyogenes, S. viridans, N.catarrhalis)
    Acute treatment: 50 mg PO 24 hrly
    Long-term treatment:
    50 mg PO 24 hrly x 10 days
    Adverse Reactions
    • GI effects (nausea, diarrhea, upper abdominal pain, gastric upset); Other effects (skin itching, cutaneous reactions, urological problems)

    Special Instructions

    • Contraindicated in patients with autoimmune disease, cardiopulmonary insufficiency, conditions with compromised immunity, active TB, rheumatic disease
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