Doctors Peter Schochet MD and Hauw Lie are experts in treating severe asthma in children and young adults. While many patients’ asthma symptoms are effectively controlled with inhaled corticosteroid containing medicines, an estimated 5-10% of patients with asthma (approximately one million people) experience poor control of asthma symptoms despite aggressive use of inhaled medications.
Severe asthma in children can be divided into two categories:
- Difficult-to-treat asthma: often due to the presence of co-morbidities such as allergic rhinitis, obstructive sleep apnea, gastroesophageal reflux. Environmental factors may play a role. Poor adherence can lead to poor control.
- Treatment-resistant asthma: Asthma that is uncontrolled despite managing these other factors. It can be allergic or non-allergic.
An asthma attack is considered severe in children when the patient experiences symptoms such as:
- Inability to complete full sentences due to shortness of breath
- Use of abdominal muscles to breath
- Severe tightness in chest
- Lips have a bluish appearance due to low oxygen saturation
- Confusion, agitation, or inability to concentrate
- Wheezing that continues after multiple breathing treatments
A patient who requires frequent hospitalization, multiple rounds of oral corticosteroids per year, and/or often visits the emergency room in spite of receiving preventative asthma medications is considered to have severe asthma. Patients who experience severe asthma attacks may require additional add-on treatments to help control their symptoms. Identifying additional contributing factors 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 inflammation in the airways. In patients with severe asthma, these eosinophils are activated, enter into the lungs and cause inflammation resulting in asthma symptoms.
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, our doctors can perform a simple blood test to measure his/her eosinophil count.
Research shows that elevated eosinophils in the blood correlate with airway inflammation, asthma severity and risk of attacks. While the exact cause of eosinophilic asthma is not known, allergic responses to environmental triggers such as pollens or pet dander do not play a role.
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 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. Our doctors will help you chose the best approach based on your child’s asthma severity, allergy testing results including total IgE and blood eosinophil levels.
Xolair (omalizumab) is an injectable medication used to treat allergic asthma (asthma triggered by allergens, such as pet dander and dust mites), and can be used in children as young as 6 years old. Approximately 60% of asthma patients (80% of asthmatic school-aged children) suffer from allergic asthma. Xolair is a monoclonal antibody which is administered as a subcutaneous injection (under the skin but not in the muscle) 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 or oral steroids
- 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.
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.
Dupixent (Dupilumab) for Asthma
Dupixent (dupilumab) is an injectable monoclonal antibody that 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 new 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, the newer biologic agents Nucala, Fasenra, and dupilumab are recommended for patients 12 years of age and older. Xolair is approved for children aged 6 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 call the office of Dr. Peter Schochet and Dr. Hauw Lie.
Dr. Peter Schochet and Dr. Hauw Lie are pediatric asthma doctors nearby in Plano, Texas.