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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 | Children ≥12 years |
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Preferred
Alternative
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Preferred
Alternative
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Preferred
Alternative
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Preferred
Alternative
|
| Reference: Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2022. | ||
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
| Recommended Medications Based on Level of Control | |||
| Treatment Steps | Daily Controller Medications | ||
| Children ≤5 years | Children 6-11 years | Children ≥12 years | |
| Step 1 |
Consider this step for children with infrequent viral wheezing and no or few interval symptoms
Reliever:
|
Preferred controller:
Other controller options:
Preferred reliever:
|
Controller:
Preferred reliever:
Alternative reliever:
|
| Step 2 |
Consider this step for children with:
Preferred controller:
Other controller options:
Preferred reliever same as Step 1 |
Preferred controller:
Other controller options (any of the following):
Preferred reliever same as Step 1 |
Controller:
Other controller options (any of the following):
Preferred and alternative reliever same as Step 1 |
| Step 3 |
Consider this step for children with:
Preferred controller:
Other controller options:
Preferred reliever same as Step 1 |
Preferred controller:
Other controller options (any one of the following):
Preferred reliever same as Step 13 |
Controller:
Other controller options (any one of the following):
Preferred and alternative reliever same as Step 13 |
| Step 4 |
Consider this step for children with:
Other controller options:
Preferred reliever same as Step 1
|
Preferred controller:
Other controller options (any of the following):
Preferred reliever same as Step 13 |
Controller:
Other controller options (any of the following):
Preferred and alternative reliever same as Step 13 |
| Step 5 | N/A |
Preferred controller:
Other controller options (any of the following):
Preferred reliever same as Step 13 |
Controller:
Other controller options (any of the following):
Preferred and alternative reliever same as Step 13 |
|
Reference: Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2022. |
|||
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
- 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
- Discontinuation of inhaled corticosteroid therapy in adolescents is not advised
- Patients adequately controlled by medium- or high-dose inhaled corticosteroid:
- 50% dose reduction of inhaled corticosteroid
- Addition of leukotriene modifiers may be considered when stepping down inhaled corticosteroids dose
- 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
- 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
- Combination of low-dose inhaled corticosteroid and Formoterol is preferred for as needed relief of symptoms in children ≥12 years
- Recommended for patients with symptoms <2x/month and with no exacerbation risk factors
- Recommended as step-down therapy for patients whose asthma is well-controlled on step 2 treatment
- Intermittent inhaled corticosteroids may be an option for children ≤5 years with intermittent viral-induced wheezing and no interval symptoms especially those with underlying atopy in whom inhaled short-acting beta2-agonist is insufficient
- 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
- Combination of low-dose inhaled corticosteroid and Formoterol is the preferred therapy for step 2 taken as needed for relief of symptoms in children ≥12 years
- 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
- Use of low-dose inhaled corticosteroid with Formoterol as maintenance therapy and for symptom relief is preferred for children ≥12 years
- Medium-dose inhaled corticosteroid is preferred for children ≤5 years and 6-11 years old, and may be an alternative for children ≥12 years
- Expert referral is recommended for children ≤5 years if symptom control remains poor and/or flare-ups persist, or if side-effects from therapy are observed
- 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 with suboptimally controlled asthma, 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 in children ≤5 years
- 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 for children 6-11 years
- 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 ≥6 years of age with severe type 2 asthma or in patients aged ≥12 years of age in need of oral corticosteroid maintenance therapy
- Add-on anti-thymic stromal lymphopoietin (anti-TSLP) (Tezepelumab) may be considered for patients aged ≥12 years old with severe asthma
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
- 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, Tezepelumab)
- 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 ≥6 years old with severe eosinophilic/type 2 asthma or in patients ≥12 years old in need of oral corticosteroid maintenance therapy
- Add-on Tezepelumab as a maintenance treatment of severe asthma for patients ≥12 years of age
- 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 consider 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 |
| Reference: Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: Updated 2022. | |
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, 30 mg/day for 3-5 years old and 40 mg/day for 6-11 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
|
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| Tiotropium bromide | 1.25 mcg/puff | ≥6 yr: 2 puffs 24 hrly | |
| 2.5 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 |
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| 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 Max dose: 8 puffs/day |
Adverse Reactions
|
| 1.25 mg/2 mL soln for inhalation | 10-20 drops via nebulizer up to 6 hrly as required <6 yr: 5-20 drops 8 hrly 6-12 yr: 5-10 drops 6 hrly ≥12 yr: 10 drops 6 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 Max dose: 4 puffs/day |
|
| 100 mcg/0.3 mL soln for inhalation | 10-30 mcg (0.1-0.3 mL) via nebulizer | ||
| 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 | 7-12 yr: 0.5-1 dose inhaled 6 hrly as required For severe exacerbations: 2 doses Max dose: 4 doses/day |
||
| 2.5 mg/2 mL, 2.5 mg/mL, 5 mg/2 mL inhalation soln | <25 kg: 2.5 mg via nebulizer up to 6 hrly as required >25 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
|
| 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 ≥12 yr: 2 puffs 12 hrly, up to 4 puffs in severe cases |
|
| 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. |
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| BETA2-AGONISTS (BRONCHODILATORS) (ORAL)1 | ||
|---|---|---|
| Drug | Dosage | Remarks |
| Short-Acting | Adverse Reactions
|
|
| 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 |
|
| Orciprenaline (Metaproterenol) | ≤5 yr: 1.3-2.6 mg/kg/day PO divided 6-8 hrly Max dose: 10 mg/dose 6-9 yr or <27 kg: 10 mg PO 6-8 hrly >9 yr or ≥27 kg: 20 mg PO 6-8 hrly |
|
| Procaterol | <6 yr: 1.25 mcg/kg/dose PO 8-12 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: 6-12 yr: 4 mg PO 12 hrly Max dose: 24 mg/day >12 yr: 4-8 mg PO 12 hrly Max dose: 32 mg/day |
|
| 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 | ||
| Salbutamol | 250 mcg slow IV inj, may repeat as required
50 mcg IM/SC, may repeat 4 hrly as required IV infusion: 3-20 mcg/min IV infusion |
Adverse Reactions
|
| Terbutaline | 2-15 yr: 10 mcg/kg/dose SC/IM/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 |
≥5 yr: 100 mcg/day |
Adverse Reactions
|
| 100, 200 mcg/cap DPI; 100, 200 mcg/dose diskhaler DPI; 200 mcg/dose easyhaler DPI |
|||
| Budesonide | 100, 200 mcg/puff MDI | 6-11 yr: 100-400 mcg/day ≥12 yr: 200-800 mcg/day Nebules 1-5 yr: 500 mcg/day 6-11 yr: 250-1000 mcg/day |
|
| 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, 250 mcg/mL, 500 mcg/2 mL, 500 mcg/mL, 1 mg/2 mL soln for inhalation unit dose | |||
| Ciclesonide | 80, 160 mcg/actuation MDI |
6-11 yr: 80-160 mcg/day |
|
| Flunisolide |
500 mcg/puff MDI (CFC) | ≥6 yr: 1000 mcg/day | |
| 80 mcg/puff MDI (HFA/CFC-Free) | 6-11 yr: 160 mcg/day ≥12 yr: 320 mcg/day |
||
| Fluticasone furoate | 50, 100, 250 mcg/dose accuhaler DPI; 50, 250 mcg dose diskhaler DPI; 50, 125, 250 mcg/dose evohaler |
6-11 yr: 50 mcg/day ≥12 yr: 100-200 mcg/day |
|
| Fluticasone propionate | 50, 125, 250 mcg/puff MDI | ≥4 yr: 50 mcg/day 6-11 yr: 50-200 mcg/day ≥12 yr: 100-500 mcg/day |
|
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 |
≥5 yr: 100 mcg/day |
|
| 1Corticosteroids combined with bronchodilators are available. Please see the latest MIMS for specific formulations. | |||
| CORTICOSTEROIDS (SYSTEMIC) | ||
| Drug | Dosage | Remarks |
| Dexamethasone | Childn: 0.2-0.6 mg/kg/day IV/IM as single dose or 24 hrly |
Adverse Reactions
|
| 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 or 0.56-8 mg/kg/day (20-240 mg/m2/day) IM/IV divided 6-8 hrly |
Adverse Reactions
|
| Methylprednisolone, Prednisolone, Prednisone | 1-2 mg/kg/day PO divided 6-8 hrly x 3-5 days Max dose for <2 yr: 20 mg/day Max dose for 2-5 yr: 30 mg/day Max dose for 6-11 yr: 40 mg/day Max dose for ≥12 yr: 50 mg/day |
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| COUGH AND COLD PREPARATIONS | ||
| Drug | Dosage | Remarks |
| Acetylcysteine | 2-5 yr: 100 mg PO 6-12 hrly >6 yr: 200 mg PO 8-12 hrly |
Adverse Reactions
Special Instruction
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| Ambroxol | ≤6 mth: 3 mg PO 12 hrly 7 mth-<1 yr: 6 mg PO 12 hrly 1-2 yr: 7.5 mg PO 12 hrly 3-6 yr: 7.5 mg PO 8 hrly 7-12 yr: 15 mg PO 8-12 hrly |
Adverse Reactions
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| Bromhexine | <5 yr: 2 mg PO 8 hrly or 4 mg PO 12 hrly 5-10 yr: 4 mg PO 8 hrly >10 yr: 8 mg PO 8 hrly |
Adverse Reactions
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| Carbocisteine (Carbocysteine) | Syr <2 yr: 50 mg PO 6 hrly 2-5 yr: 200 mg PO 6 hrly 6-12 yr: 400 mg PO 8 hrly Tab 6-12 yr: 375 mg PO 8 hrly |
Adverse Reactions
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| Dried ivy leaf extract | Syr 2-5 yr: 2.5 mL PO 12 hrly 6-12 yr: 5 mL PO 12 hrly >12 yr: 5 mL PO 8 hrly Effervescent Tab 6-12 yr: 32.5 mg PO 12 hrly >12 yr: 65 mg PO in the morning and 32.5 mg PO in the evening |
Adverse Reactions
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| Guaifenesin | 2-5 yr: 50-100 mg PO 4 hrly 6-11 yr: 100-200 mg PO 4 hrly ≥12 yr: 200-400 mg PO 4 hrly Max Dose: 600 mg/day or 6 doses/day |
Adverse Reactions
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| Lagundi (Vitex negundo) | 15 mg/kg PO 8 hrly | Adverse Reactions
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| 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
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|
| 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
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| Pranlukast | 3.5 mg/kg PO 12 hrly Max dose: 10 mg/kg/day |
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| Zafirlukast | 5-11 yr: 10 mg PO 12 hrly ≥12 yr: 20 mg PO 12 hrly |
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| 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 |
Adverse Reactions
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| MONOCLONAL ANTIBODIES | |||
|---|---|---|---|
| Drug | Dosage | Remarks | |
| Anti-Immunoglobulin E (Anti-IgE) Antibody | |||
| Omalizumab | 6-11 yr: 75-375 mg in 1-3 SC every 2 or 4 week ≥12 yr: 150-375 mg SC every 2 or 4 week Dose depends on pretreatment IgE level and body weight |
Adverse Reactions
Special Instructions
|
|
| Interleukin Inhibitors | |||
| Benralizumab | ≥12 yr: 30 mg SC every 4 week x 3 doses, then every 8 week | Adverse Reactions
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|
| Dupilumab | 6-11 yr, 15-<30 kg: 100 mg SC every other week or 300 mg SC every 4 weeks or 600 mg (300 mg x 2doses) SC followed by 300 mg SC every 4 weeks 6-11 yr, 30-<60 kg: 200 mg SC every other week or 400 mg (200 mg x 2doses) SC followed by 200 mg SC every other week 6-11 yr, ≥60 kg: 600 mg(300 mg x 2 doses) SC followed by 300 mg SC every other week ≥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
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|
| Mepolizumab | 6-12 yr: 40 mg SC 24 hrly every 4 wk ≥12 yr: 100 mg SC 24 hrly every 4 wk |
Adverse Reactions
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| Thymic Stromal Lymphopoietin Blocker | |||
| Tezepelumab | ≥12 yr: 210 mg SC every 4 week |
Adverse Reactions
Special Instructions
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| 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
Special Instructions
|
|
| Xanthines (Oral) | ||
| Drugs | Dosage | Remarks |
| Acefylline | 500 mg-2 g/day PO in divided doses |
Adverse Reactions
Special Instructions
|
| Aminophylline | Dosage should be individualized | |
| Choline theophyllinate | 100-200 mg PO 6-8 hrly or 10-20 mg/kg/day PO 6 hrly or <5 yr: 24-36 mg/kg/day PO divided 8 hrly 5-9 yr: 200-400 mg/day PO divided 6 hrly 10-14 yr: 400-800 mg/day divided 6 hrly |
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| Doxofylline | <12 yr: 6-9 mg/kg/dose PO 12 hrly >12 yr: 400 mg PO 8-24 hrly |
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| Heptaminol acefyllinate | Oral drops <7 yr: 2-3 drops/kg/day PO divided 8 hrly 7-15 yr: 75-100 drops/day PO divided 8 hrly >15 yr: 25-50 drops PO 8 hrly Tab >15 yr: 500 mg-1 g PO 8 hrly |
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| Theophylline1 | Dosage should be individualized based on serum Theophylline levels 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: 24 mg/kg/day PO 9-<12 yr (including adolescent smokers):20 mg/kg/day PO 12-16 yr (nonsmokers): 18 mg/kg/day PO ≥16 yr (nonsmokers): 13 mg/kg/day PO |
|
| 1Different formulations for Theophylline are available. Please see the latest MIMS for specific formulations. | ||
| Xanthines (Parenteral) | ||
| Drug | Dosage | Remarks |
| Acefylline | 1.5-2 g/day IM or 0.5-1 g/day IV |
Adverse Reactions
Special Instructions
|
| Aminophylline | Loading dose: 5 mg/kg IV infusion over 20-30 min Maintenance dose: 6 mth-9 yr: 1 mg/kg/hr IV 10-16 yr: 0.8 mg/kg/hr IV |
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