Step 3 therapy for children 6 years and older
Few children aged 6 years and older require Step 3 therapy to control symptoms. Step 3 therapy can be considered in children who do not achieve good control with Step 2 therapy, despite good adherence and inhaler technique, and after exclusion of alternative diagnoses.
If Step 3 therapy is required, use one of the following options:
- a high paediatric dose of ICS
- a low paediatric dose of ICS plus a long-acting beta2 agonist (LABA) (given as a fixed-dose combination)
- a low paediatric dose of ICS plus montelukast.
High-dose ICS or low-dose ICS+LABA may be more effective than ICS plus montelukast, although response varies widely among children. ICS plus montelukast appears to be more effective than ICS+LABA for children with exercise-induced bronchoconstriction.
If a high paediatric dose of ICS, with SABA reliever therapy, is preferred, use:
a SABA as required (see Step 1 for dosage)
PLUS ONE OF THE FOLLOWING
1 fluticasone propionate 125 to 250 micrograms by inhalation via pMDI with spacer or via DPI, twice daily1 asthma, Step 3 therapy (child 6 years or older) fluticasone propionate
OR
1 ciclesonide 240 to 320 micrograms by inhalation via pMDI with spacer, once daily asthma, Step 3 therapy (child 6 years or older) ciclesonide
OR
1 budesonide 300 to 400 micrograms by inhalation via DPI, twice daily12 asthma, Step 3 therapy (child 6 years or older)[ asthma, Step 3 therapy (child 6 years or older) budesonide
OR
1 beclometasone 200 micrograms by inhalation via pMDI with spacer, twice daily. asthma, Step 3 therapy (child 6 years or older) beclometasone
If a low paediatric dose of ICS+LABA is preferred, always use a fixed-dose combination inhaler; using separate inhalers increases the risk of the child using LABA alone, which is associated with increased risk of exacerbations. Use:
a SABA as required (see Step 1 for dosage)
PLUS
fluticasone propionate+salmeterol 100+50 micrograms by inhalation via pMDI with spacer or via DPI, twice daily1 asthma, Step 3 therapy (child 6 years or older). asthma, Step 3 therapy (child 6 years or older) fluticasone propionate + salmeterol
If a low paediatric dose of ICS plus montelukast is preferred, use the dosages outlined in Step 2 with SABA reliever therapy.
For children aged 12 years and older, consider the use of budesonide+formoterol maintenance and reliever therapy. Budesonide+formoterol maintenance and reliever therapy is associated with a lower risk of exacerbations than ICS+LABA maintenance plus SABA reliever therapy. For Step 3 therapy with low-dose budesonide+formoterol maintenance and reliever therapy, use the dose outlined here. Budesonide+formoterol maintenance and reliever therapy is not approved for use in children under 12 years old.
Assess symptom control after 4 to 6 weeks. See Assessment of asthma control in children for details about review, and definitions of good, partial and poor control.
If symptoms are well controlled, continue treatment and review the child again after 3 months. Therapy may be able to be stepped down if control remains good—see Stepping down asthma therapy in children.
If symptoms remain uncontrolled with Step 3 therapy, or if good control cannot be maintained 3 to 6 months after stepping down from Step 3 therapy, review the diagnosis and arrange referral to a paediatrician or paediatric respiratory physician. See also Severe asthma in children for information on specialist treatments for asthma.