Paediatric Pulmonology and Allergology

2003 October, Vol. VI, No. 2 (pp.2261-2276)

Long-Acting b₂-Agonists in Management of Childhood Asthma: A Critical Review of the Literature

Hans Bisgaard

This re­view as­ses­ses the evi­den­ce re­gar­ding the use of long-ac­ting b₂-ago­nists in the ma­na­ge­ment of pe­diat­ric ast­hma. Ther­ty doub­le-blind, ran­do­mi­sed, con­trol­led trials we­re re­vie­wed. Sin­gle do­ses of in­ha­led sal­me­te­rol or for­mo­te­rol cau­se pro­lon­ged bron­cho­di­la­ta­tion (mo­re than 12 h) and ex­ten­ded bron­chop­ro­tec­tion against exer­ci­se-in­du­ced bron­chop­ro­tec­tion in chil­dren, so­me chil­dren achie­ving full pro­tec­tion for mo­re than 12 h. He­te­ro­ge­nei­ty in bron­chop­ro­tec­tion has be­en ob­ser­ved, and in­di­via­du­al do­se-tit­ra­tion may be at­temp­ted. The on­set of ac­tion of for­mo­te­rol is com­pa­rab­le to sal­bu­ta­mol, whi­le sal­me­te­rol has a slo­wer on­set of ac­tion. Par­tial to­le­ran­ce de­ve­lops when long-ac­ting b₂-ago­nists are used as re­gu­lar tre­at­ment, inc­lu­ding cross-to­le­ran­ce to short-ac­ting b₂-ago­nists. Re­gu­lar tre­at­ment with sal­me­te­rol in chil­dren with or wit­hout cor­ti­cos­te­roids pro­vi­des sta­tis­ti­cal­ly sig­ni­fi­cant bron­cho­di­la­ta­tion, but de­gree of im­pro­ve­ment in lung func­tion or bron­chop­ro­tec­tion against exer­ci­se and nons­pe­ci­fic ir­ri­tants is small with re­gu­lar use. The­re is no evi­den­ce of an­ti-in­flam­ma­to­ry ef­fects from in­ha­led long-ac­ting b₂-ago­nists, which is re­flec­ted by un­chan­ged or inc­re­a­sed bron­chial hy­per­re­ac­ti­vi­ty and no re­duc­tion of exa­cer­ba­tion ra­tes. The evi­den­ce do­es not sup­port a re­com­men­da­tion for long-ac­ting b₂-ago­nists as mo­not­he­ra­py, nor do­es not sup­port their ge­ne­ral use as re­gu­lar add-on the­ra­py. In conc­lu­sion, long-ac­ting b₂-ago­nists pro­vi­de ef­fec­ti­ve bron­cho­di­la­ta­tion and bron­chop­ro­tec­tion when used as in­ter­mit­tent, sin­gle-do­se tre­at­ment of ast­hma in chil­dren, but not when used as re­gu­lar tre­at­ment. Fu­tu­re stu­dies should exa­mi­ne the po­si­tio­ning of long-ac­ting b₂-ago­nists as an “as ne­eded”res­cue me­di­ca­tion ins­te­ad of short-ac­ting b₂-ago­nists for pe­diat­ric ast­hma ma­na­ge­ment.

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