Treatment of Pediatric Asthma with Proton Pump Inhibitors: Three Strikes, Game Over

Empiric use of proton pump inhibitors (PPI) for the treatment of poorly controlled asthma has increased substantially in the past decade under the presumption that gastroesophageal reflux is precipitating symptoms. No PPI has a Food and Drug Administration (FDA) approved indication for the treatment of asthma symptoms. Use has been driven by data indicating that up to 80% of children and adults with asthma have reflux by pH probe monitoring and that nearly half of patients lack typical reflux symptoms. Data from controlled studies of adults have shown only a minimal improvement in peak expiratory flow with PPI use in the overall population, with only a slightly larger improvement in patients with diagnosed gastroesophageal reflux disease, and no effect on asthma exacerbation rate in one study. The single largest placebo-controlled study in children with poorly controlled asthma without gastroesophageal reflux symptoms found no improvement in any indices of asthma control, even in children with gastroesophageal reflux by pH probe test. In children, there is a disturbing increased risk for respiratory tract infections and potentially for activity related fractures with PPI treatment. These effects are consistent with known adverse effects of PPIs. Thus use of PPI should be confined to children with asthma who also have overt symptoms of gastroesophageal reflux. PPI are unlikely to improve poorly controlled asthma.