Asthma Control Not Improved With School-Supervised Inhaled Corticosteroid Use

A program of school-supervised use of once-daily inhaled corticosteroid (ICS) medication failed to improve asthma control, school absences, or healthcare use in a population of primarily Latino children from low-income households according to a study published in the Journal of Allergy and Clinical Immunology.

Adherence to ICS is poor in children with asthma. For example, only 25% were found to exceed 80% adherence during the Childhood Asthma Management Program study (ClinicalTrials.gov Identifier: NCT01997463), and nonadherence is an important cause of morbidity in children with asthma. Making use of schools to improve adherence in disadvantaged urban minority populations, who often have the poorest adherence and the greatest morbidity, has been proposed as a potential cost-effective intervention.

Researchers conducted a cluster-randomized trial of supervised therapy in 20 elementary schools. Students with self-reported asthma were eligible and received mometasone furoate or usual care. The investigators used the Asthma Control Questionnaire (ACQ) to assess disease control.

Of 393 students who enrolled in the trial, 189 received either immediate intervention and 143 received delayed intervention (first year on usual care and second year with school-based intervention). At baseline, 39% of students reported taking a controller medication, and 24% had well-controlled asthma. Although schools administered 98% of prescribed doses of ICS, absences, weekends, holidays, and summer vacation reduced overall adherence to 53%.

The mean ACQ score during the first year was 1.55 (95% CI, 1.41-1.70) in the immediate intervention group and 1.64 (95% CI, 1.47-1.80) in the delayed intervention group. The estimated treatment effect was –0.08.

The investigators noted that the failure to find improvement was not likely the result of inadequate power as the lower bound of the 95% CI estimating the improvement in ACQ score, 0.31 units, was smaller than the instruments 0.4- to 0.5-unit minimally important difference. Furthermore, the lack of improvement in healthcare use or school attendance corroborates this finding.

The investigators suggested several possible reasons for the failure to find benefit for the program. Unlike previous studies, this study did not provide any intervention for improving treatment adherence at home. It has been suggested that in order to improve outcomes in asthma control, 80% or greater adherence must be achieved. In this study, due to school absences, vacations, holidays, and weekends, adherence was only 53%. Other studies included populations of primarily black and white students, so it is possible that ICS does not work as well in primarily Latino populations. Finally, asthma control was assessed using ACQ scores reported by the children themselves.

Reference

Gerald JK, Fisher JM, Brown MA, et al. School-supervised use of a once-daily inhaled corticosteroid regimen: a cluster randomized trial [published online July 27, 2018]. J Allergy Clin Immuno. doi:10.1016/j.jaci.2018.06.043