Asthma%20(pediatric) Treatment

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
Treatment Steps	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 Formoterol^1,2 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 Formoterol^1,2 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.⁸For 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
Fenoterol	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
Salmeterol	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
Beclomethasone dipropionate	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
Dried ivy leaf extract
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

A Guide on Primary Immunodeficiency Disease and Allergies

05 Feb 2021

Primary immunodeficiency disease (PIDD) and allergies are two groups of conditions related to the immune system. However, they are uniquely different in terms of symptoms and treatment.