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PICO Question

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by

Caleb Cook

on 14 January 2015

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Transcript of PICO Question

PICO Question
Caleb J. Cook PGY1
Population
Pediatric patients with mild to moderate persistent asthma with not well to poor control

Conclusions?
Over prescribed?
Consider medium dosed ICS over low + Montelukast for Step 2
Consider medium dosed ICS plus LABA over Montelukast
Individualize Each Patient
Thank you!
Patient Scenario
8 year old Caucasian Female
PMH
Mild persistent asthma diagnosed at age 4
Currently on low dose ICS
Seen in clinic for hospital f/u for asthma exacerbation
Second exacerbation requiring steroids this year
Searching...
Mesh Terms
Montelukast OR Antileukotriene AND Asthma, pediatric
Results
1. Addition of anti-leukotriene agents to inhaled corticosteroids in children with persistent asthma. Chauhan BF, Ben Salah R, Ducharme FM.Cochrane Database Syst Rev. 2013 Oct 2;10:CD009585. doi: 10.1002/14651858.CD009585.pub2.
2.Ten-year prescription trends of asthma medications in the management of childhood wheeze. Soh JY, Ng B, Tan Z, Xu S, Hing WC, Wu TS, Chan YH, Lee BW. Allergy Asthma Proc. 2014 Jan-Feb;35(1):e1-8. doi: 10.2500/aap.2014.35.3712.
Question?
Does the addition of anitleukotriene agents to ICS prevent use of oral steroids and/or hospital admissions compared to ICS alone in pediatric patients with poorly controlled mild to moderate asthma?
Intervention
The addition of anti-leukotriene agents to ICS
Comparison
ICS alone at same or higher doses
Outcome
Fewer uses of oral steroids and hospital admissions
2007 NHLBI Guidelines
Ten-year prescription trends of asthma medications in the treatment of childhood wheeze
Retrospective study of data obtained from outpatient prescription databases.
Number of school age children treated with LABA-ICS decreased by 32.4% (p=0.003)
Rise in the number of montelukast patients by 194.6% (p=0.009)
Addition of anti-leukotrine agents to inhaled corticosteroids in children with persistent asthma - Cochrane Review
Selection criteria
RCT's of symptomatic pediatric asthmatics on stable ICS dose who had Monteleukast added compared to same or higher dose ICS
5 trials met criteria; two with a low risk of bias
3 compared Step 2 to Step 3 (same ICS vs ICS-LTRA)
2 compared Step 3 to Step 3 (higher ICS vs ICS-LTRA)
In no trial was there a significant difference found in the number of hospital admissions or exacerbations requiring oral steroids.
Authors concluded that large lack of data despite ten years of pediatric approval with few trials performed, especially in preschool children
Variability in outcome reporting of relevant patient outcomes
Full transcript