Severe asthma in children is treated by our pediatric pulmonologists in Plano, Dr. Schochet and Dr. Lie. While many asthma patients’ symptoms are effectively controlled with inhaled or oral corticosteroids, an estimated 5-10% of patients with asthma (approximately one million people) experience severe and/or sustained symptoms which remain uncontrolled despite these treatments. Severe asthma in children can be divided into two categories:
- Difficult-to-treat asthma: Poorly controlled asthma often due to co-morbidities (such as allergic rhinitis, obstructive sleep apnea, or gastroesophageal reflux) or environmental factors
- Treatment-resistant asthma: Asthma that is uncontrolled despite managing these factors.
An asthma attack is considered severe asthma in children when the patient experiences symptoms such as:
- Inability to complete full sentences due to shortness of breath
- Continued breathlessness even upon lying down
- Tightness in chest
- Lips have a blueish appearance
- Confusion, agitation, or inability to concentrate
- Wheezing that continues after breathing treatments
A patient who requires frequent hospitalization or often visits the emergency room in spite of receiving asthma treatments and medications is considered to have severe asthma. Patients who experience severe asthma attacks may require additional add-on treatments to help control their conditions. Identifying any factors that are contributing to the lack of controlled asthma symptoms can also improve treatment success.
Approximately half of patients with severe asthma have a condition called eosinophilic asthma. Eosinophils are white blood cells which are part of the normal immune system that can become overactive and cause swelling. In patients with severe asthma, these eosinophils, once activated, can enter into the lungs and cause inflammation resulting in asthma symptoms or a severe asthma attack.
Although more common in adults, eosinophilic asthma can present in children, especially those with chronic sinus problems. To determine if your child has eosinophilic asthma, your pediatric pulmonologist can administer a simple blood test to measure his/her eosinophil count.
Research shows that elevated eosinophils in the blood increase future severity and risk of asthma attacks. While the exact cause of eosinophilic asthma is not known, there is no evidence that allergies act as a contributor.
How Do You Treat Severe Asthma in Children?
Severe asthma in children is characterized by its resistance to or lack of significant improvement with inhaled corticosteroids, which are typically extremely effective at treating asthma. In many cases, asthma treatment in children over 12 who don’t respond to standard treatments can be augmented with additional medications which can result in increased symptom control, as well as fewer asthma attacks.
Current add-on treatments include Xolair and other new biologic agents for asthma called Nucala, Fasenra, and soon-to-be available dupilumab.
Xolair (omalizumab) is an injectable medication used to treat allergic asthma (asthma triggered by allergens, such as pet dander and dust mites). Approximately 60% of asthma patients (80% of asthmatic school-aged children) suffer from allergic asthma. Xolair is a genetically humanized monoclonal antibody which is administered 1-2 times per month for long-term asthma control. Symptoms are controlled by decreasing the likelihood of the body experiencing an allergic reaction when exposed to an allergen trigger.
Patients using Xolair report:
- Decrease in asthma attacks, as well as severity of attacks
- Improved long-term symptom control
- Significant decrease in the need for inhaled corticosteroids
- Fewer hospitalizations due to asthma attacks
New Biologic Agents for Severe Asthma
Nucala (mepolizumab) is an injectable monoclonal antibody which reduces eosinophils in the blood resulting in decreased airway inflammation thus preventing or reducing the severity of asthma attacks. Nucala injections are administered once a month as an add-on treatment to asthma patients’ standard therapy. Nucala comes in powder form and must be mixed with liquid to administer as an injection, which can be done at home after your pediatric pulmonologist has instructed you.
Benefits of Nucala can include:
- Significant reduction in hospitalizations and ER visits due to asthma attacks
- Reduction in occurrences and/or prevention of severe asthma attacks
- Decreased need for oral steroids, such as prednisone
- Increased quality of life
Nucala injections should be given every 4 weeks even when the patient is feeling better, as biologic agents treat the source of asthma attacks rather than the symptoms. Nucala is not a treatment for sudden breathing problems.
Fasenra (benralizumab) is an add-on injectable maintenance treatment for severe eosinophilic asthma patients. As a respiratory biologic agent, Fasenra reduces eosinophils in the blood that trigger airway inflammation resulting in severe asthma attacks. Fasenra is administered once every 4 weeks for the first 3 months, then continued once every 8 weeks thereafter. Because Fasenra is only injected every 8 weeks, it is important to keep your scheduled appointments to maintain treatment success.
Patients using Fasenra have shown:
- Significant improvement in pulmonary function
- Decrease in asthma symptoms, such as coughing, chest tightness, and shortness of breath
- Reduced need for oral steroids (by up to 70%)
Some patients using Fasenra are able to completely stop the use of oral steroids. Reducing oral steroids use can be extremely beneficial to overall health as long-term steroid use can be a contributor to many medical conditions including:
- Weight gain
- Certain heart conditions
- Stomach ulcers
- High blood pressure
- Bone fractures
Patients should not stop taking oral or inhaled steroids without doctor approval. Like other biologic agents for asthma, Fasenra is not intended to treat sudden breathing problems.
Coming soon…Dupixent (Dupilumab) for Asthma
Dupixent (dupilumab) is an injectable human monoclonal antibody which has been given an FDA review deadline of October 2018 as a treatment for severe asthma. Dupilumab (an anti-inflammatory drug) has been recently approved and used for the treatment of atopic dermatitis (eczema), and now research suggests a link between asthma and eczema. Studies conducted with severe asthma patients revealed that dupilumab was effective at:
- Increasing pulmonary function
- Decreasing emergency room visits due to severe asthma attacks
- Reducing asthma symptoms
Up to 80% of patients in the double-blind randomized study who received dupilumab were able to reduce oral steroids by half (50% were completely steroid-free).
At this time, biologic agents Nucala, Fasenra, and dupilumab are recommended for patients 12 years of age and older. These groundbreaking new treatments are providing exciting results in asthma control, as well as insight into the physiological elements and mechanics of the disease.
If your child has severe/uncontrolled asthma or if you would like more information about add-on treatments with biologic agents, please contact our office for an appointment. Please submit an online appointment request or contact the office of Dr. Peter Schochet and Dr. Hauw Lie at 972-981-3251.