International Consensus on Childhood Asthma (ICON) – anew attempt to unify the guidelines

International Consensus on Childhood Asthma (ICON) – anew attempt to unify the guidelines

Oral Presentations / Paediatric Respiratory Reviews 14S2 (2013) S1–S53 whether an intervention has a benefit under ideal circumstances. However, since...

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Oral Presentations / Paediatric Respiratory Reviews 14S2 (2013) S1–S53

whether an intervention has a benefit under ideal circumstances. However, since RCTs are performed in highly selected patient populations, they do not apply to real life asthma patients. Only a small minority of patients with asthma are eligible for asthma RCTs, estimated as a few percent [13]. The goal of pragmatic trials and observational studies instead is to understand real-life efficacy, known as effectiveness. They aim to assess treatment outcomes in real-life clinical practice. Pragmatic trial design incorporates relevant practice settings, everyday (usual) clinical practice, a heterogeneous patient population [13]. Real life studies in adult asthma populations have shown different results as compared to the outcome of RCTs [14] and may offer extra information to clinicians. Clinicians who treat children with asthma have little-real life evidence on which to base their therapeutic choices. Children may benefit of small particles ICS because of their smaller airways, since small airways dysfunction is associated with asthma control. Information on the real-life effectiveness for children initiating ICS therapy with extra-fine BDP as compared with FP is therefore important. The same is true for real life effectiveness for children of stepping up asthma therapy by increasing ICS as extrafine BDP versus using a combination of ICS plus long-acting b2 -agonist therapy. References [1] Durrani SR, Viswanathan RK, Busse WW. What effect does asthma treatment have on airway remodeling? Current perspectives. J Allergy Clin Immunol 2011 Sep; 128(3): 439–48. [2] Malmstrom ¨ K, Pelkonen AS, Malmberg LP, Sarna S, Lindahl H, Kajosaari M, Turpeinen M, Saglani S, Bush A, Haahtela T, Jeffery PK, Makel ¨ a¨ MJ. Thorax 2001; 66: 157–62. doi: 10.1136/thx.2010.139246. Epub 2011 Jan 2. [3] Suisa S, Ernst P. Inhaled corticosteroids: impact on asthma morbidity and mortality. J Allergy Clin Immunol 2001; 107: 937–44. [4] Steenhuis TJ, Landstra AM, Verberne AAPH, Van Aalderen WMC. When asthma interrupts sleep in children; what is the best strategy? BioDrugs 1999; 12: 431–8. [5] Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidencebased approach. Eur Respir J. 2008; 32: 1096–110. [6] Kraft M, Djukanovic R, Wilson S, Holgate ST, Martin RK. Alveolar tissue inflammation in asthma. Am J Respir Crit Care Med 1996; 154: 1505–10. [7] Hyde DM, Hamid Q, Irving CG. Anatomy, pathology, and physiology of the tracheobronchial tree: emphasis on the distal airways. J Allergy Clin Immunol 2009; 124: S72-S77. [8] Adcock IM, Gilbey T, Gelder CM, Chung KF, Barnes PJ. Glucocorticosteroid receptor localization in normal and asthmatic lung. Am J Respir Crit Care Med 1996; 154: 771–82. [9] Leach CL, Davidson PJ, Boudreau RJ. Improved airway targeting with the CFC-free HFA-beclomethasone metered-dose inhaler compared with CFC-beclomethasone. Eur Respir J 1998; 12: 1346–53. [10] Van Schayck CP, Donnell D. The efficacy and safety of QVAR (hydrofluoroalkane-beclometasone dipropionate extrafine aerosol) in asthma (Part 2): clinical experience in children. Int J Clin Pract 2004; 58: 786–94. [11] Szefler SJ, Warner J, Doris Staab D, Wahn U, Le Bourgeois M, Van Essen-Zandvliet EEM, Arora S, Pedersen S, on behalf of the Pediatric Study Group. Switching from conventional to extrafine aerosol beclomethasone dipropionate therapy in children: A 6-month, open label, randomized trial J Allergy Clin Immunol 2002; 110: 45–50. [12] Van Aalderen WM, Price D, De Baets FM, Price J. Beclometasone dipropionate extrafine aerosol versus fluticasone propionate in children with asthma. Respir Med. 2007; 101: 1585–93. [13] Price D, Hillyer E V. Van der Molen T. Efficacy versus effectiveness trials: informing guidelines for asthma management. Curr Opin Allergy Clin Immunol. 2013; 13: 50–7. [14] Price D, Musgrave SD, Shepstone L, Hillyer EV, Sims EJ, Gilbert RF, Juniper EF, Ayres JG, Kemp L, Blyth A, Wilson EC, Wolfe S, Freeman D, Mugford HM, Murdoch J, Harvey I.Leukotriene antagonists as first-line or add-on asthma-controller therapy. N Engl J Med. 2011 May 5;364(18): 1695–707.


OLD-07 International Consensus on Childhood Asthma (ICON) – a new attempt to unify the guidelines P. Pohunek, on behalf of the group of authors. Prague, Czech Republic Asthma is the most frequent disorder of respiratory tract in children. Most of the cases originate in early childhood. There may be some difficulties in differencial diagnosis as early asthma may present in various phenotypes. Several groups have attempted to standardize the diagnostic and therapeutic approch to a child with suspected or confirmed asthma. There are now several guidelines and/or consensus documents available to support diagnostic and therapeutic decisions on pediatric asthma. The International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma [1]. The aim of this consensus document was to compare several existing pediatric guidelines, identify common key messages and recommendations and provide comments and critical review of differences between reviewed guidelines. The principles of pediatric asthma management are generally accepted in all the documents. ICON points out the importance of different age groups, the main milestones being 2, 5, 12 and 18 years of age. Main goal of the treatment is disease control. ICON provides a modified scheme for evaluation of asthma control that corresponds to practice and includes a definition of complete control. The importance of education and training of a patient and the family is stressed as essential for achieving full adherence and collaboration with the health care provider. Without understanding of the principles of the disease and its management optimal outcome of the treatment cannot be achieved. Identification and avoidance of triggers is also of significant importance. Regular assessment and monitoring should be performed to re-evaluate and optimally fine-tune treatment. Cornerstone of the treatment is pharmacotherapy. All the documents provide a step-wise approach that has many common steps but also some differences. Overall, the anti-inflammatory treatment remains the main therapeutic option in all age groups. It is again stated that the systematic therapeutic approach and optimal use of medication can control symptoms in most patients and is essential for reduction of the risk for future morbidity. The management of exacerbations has also been reviewed in details. It is shown that assessment and management of asthma exacerbations must be considered independently of chronic treatment. High dose frequent application of rapid acting beta-2 agonists are recommended together with oral corticosteroids as main therapeutic steps in a developing acute exacerbation. The document shows also some of the possible future directions, mainly the possibility of phenotype specific treatment. All the paragraphs in the document are supplemented with a suggestion for future guideline updates and recommendations for future research directions. References [1] Papadopoulos N., G.H. Arakawa, K.-H. Carlsen, A. Custovic, J. Gern, R. Lemanske et al. International consensus on (ICON) pediatric asthma Allergy. 2012 Aug; 67(8): 976–97.