FCAAIA Notes: Are you a glass is half-full or half-empty type of person? Your answer might change the way you interpret this study. The “half-empty” person might look at this and say, “OMG!!! Children with asthma who were treated long-term with inhaled corticosteroids (ICS) averaged 1.2 cm less adult height than those who were not!”
Well, I’m a half-full person. I look at this study and see other things. These were mild asthmatics who probably were treated with more ICS than they actually needed to control their disease. The growth suppression here was all very early in treatment and was not at all progressive over time. This is the first study ever to show that long-term use of ICS impacts adult height but you cannot use statistics to prove a negative thing. So, one positive study result gets a lot of press. Also, we are talking about ½ an inch, even if the results are reproducible. Finally, this study does not look at the effect of poorly controlled asthma on growth (it suppresses it), or the risk of poorly controlled asthma on overall health, or the risks of repeated short bursts of oral steroids for asthma flares.
Like everything else, the risks and benefits of ICS in asthma need to be compared. That is why we always aim to keep your asthma in the best control it can be with as little medication as it takes to do so.
(Source: http://www.medscape.com/viewarticle/770524?src=mp&spon=38 September 18, 2012. Adapted from N Engl J Med. 2012;367:904-912). For Medscape articles: User name: FCAAIA, Password: Allergies
A large study presented here at the European Respiratory Society (ERS) 2012 Annual Congress showed that corticosteroid use to control asthma in children affected the height they attained as adults by only about 1 cm.
Anne Fuhlbrigge MD, from Brigham and Women’s Hospital in Boston, Massachusetts, presented results from the Childhood Asthma Management Program (CAMP) trial in a joint ERS/NEJM Symposium. The results were also simultaneously published in the September 6 issue of the New England Journal of Medicine.
Concerns over adverse effects of glucocorticosteroids on bone mineral density prompted the study.
The CAMP investigators initially enrolled 1041 children aged 5 to 13 years with mild to moderate asthma who were randomly assigned to receive 400 μg budesonide, 16 mg nedocromil, or placebo daily for 4 to 6 years. Serial dual-energy X-ray absorptiometry scans of the lumbar spine for bone mineral density were performed in all patients.
Bone mineral accretion was determined annually in 84% of the initial cohort, or 531 boys and 346 girls who participated in CAMP.
The median follow-up was 7 years. Adult height was measured at age 18 years in girls and age 20 in boys. If measurements were not made at these ages, measurements were taken later twice at intervals at least 1 year apart.
Corticosteroids Had Little Effect on Adult Height
The investigators found that height differed by less than 1 cm between those who received corticosteroids during childhood and those who did not.
Differences in adult height for each active treatment group compared with placebo were determined using multiple linear regression with adjustment for demographic characteristics, asthma features, and height at trial entry.
According to Søren Pedersen, MD, PhD, from KoldingHospital in Denmark, asthma can be controlled in most children at doses of 200 μg corticosteroids per day, but larger doses do not significantly affect outcomes.
“More than 90% of dose-response studies have failed to show any difference between adjacent doubled doses of inhaled steroids on normally measured outcomes,” Dr. Pedersen said.
Mean adult height was found to be 1.2 cm lower (95% confidence interval, −1.9 to −0.5 cm) in participants who had received budesonide during childhood than in the placebo group ( P = .001).
Mean adult height was 0.2 cm lower (95% confidence interval, −0.9 to 0.5 cm) in the nedocromil compared with the placebo group ( P = 0.61). The adjusted mean heights for the budesonide and placebo groups were 171.1 and 172.3 cm, respectively (P = .0001). Mean adult height (172.1 cm) in the nedocromil group did not differ significantly from that of the placebo group ( P = .61).
A larger daily dose of inhaled glucocorticoid during the first 2 years of treatment was associated with a decrease in adult height of 0.1 cm for each microgram per kilogram of body weight ( P = .007).
According to Stanley Fineman, MD, president of the AmericanCollege of Allergy, Asthma and Immunology, the dose of inhaled steroids mentioned in the study dates back to the 1990s and is double the dose that allergists usually prescribe today.
The reduction in adult height in the budesonide group compared with the placebo group was 1.3 cm (95% confidence interval, −1.7 to −0.9) during the first 2 years of treatment. The deficit in adult height was greater compared with placebo (−1.8 cm; P = .0001) in women than in men (−0.8 cm; P = .10).
According to Dr. Fuhlbrigge, “growth velocity differed during the first 2 years of treatment with budesonide vs placebo. In both sexes, the reduction in velocity was primarily among prepubertal participants.”
Factors other than glucocorticoids that influenced adult height were Hispanic race, vitamin D insufficiency at baseline, lower height on study entry, greater body mass index, and a longer duration of asthma.
Dr. Pedersen stressed that the adverse effects of uncontrolled asthma far outweigh concerns about the effect of corticosteroids on growth. “One year of inhaled glucocorticosteroid treatment increased the daily physical activity by 3 hours per week and resulted in markedly improved cardiovascular fitness,” he pointed out.
Dr. Fuhlbrigge added that “the initial decrease of approximately 1 cm in attained height associated with the use of inhaled glucocorticoids in children persists as a reduction in adult height, but is neither progressive nor cumulative. The possible effect on adult height must be weighed against the well-established benefits of glucocorticosteroids in controlling asthma.”
“It is appropriate to use the lowest effective dose [of corticosteroids] for symptom control to minimize concerns about adult height,” she commented.