Optimizing maintenance therapy in pediatric asthma

Purpose of review There are different phenotypes of asthma, with phenotype-specific differences in medication response observed. Recent findings Tobacco smoke exposure reduces corticosteroid responsiveness. Treatment for tobacco smoke-triggered asthma must start with treatment of tobacco dependence. Obesity-associated asthma responds to weight loss and treatment of comorbidities. Immunotherapy and omalizumab are specific therapies for atopic asthma, though its use is limited by expense, inconvenience, need for injections, and toxicities. Leukotriene modifier response is more prominent in viral-triggered asthma. Research on intermittent escalation of controller therapy for asthma shows best results when escalation is substantial and early. Inhaled corticosteroid medications in low-to-moderate doses remain the most important maintenance medication for a broad variety of asthma phenotypes, reducing both impairment and risk. When impairment is not fully controlled by an inhaled corticosteroid, combination with a long-acting beta-agonist, leukotriene modifier, or theophylline can be effective. Inhaled corticosteroid use in children does not appear to influence airway caliber or asthma severity after the medication is stopped. Summary Optimizing maintenance therapy for asthma is not one size fits all. It is important to assess the asthma phenotype in addition to the symptom pattern, in determining optimal maintenance therapy.