| Medication | Dose form | 0 to 4 years | 5 to 11 years | Comments |
| Leukotriene receptor antagonists (LTRAs)¶ | ||||
| Montelukast | 4 mg or 5 mg chewable tablet 4 mg granule packets | 4 mg once daily at bedtime (1 to 5 years of age). | 5 mg once daily at bedtime (6 to 14 years of age). | When LTRA treatment is indicated, montelukast is preferred. |
| Zafirlukast | 10 mg tablet | Safety and efficacy not established. | 10 mg twice per day on empty stomach. | Zafirlukast has potential drug interactions and a small risk of hepatotoxicity. Food decreases bioavailability of zafirlukast; take at least 1 hour before or 2 hours after meals. |
| Combined inhaled glucocorticoids and long-acting beta agonists (LABAs)Δ | ||||
| Fluticasone-salmeterol | DPI 100 mcg/50 mcg | Safety and efficacy not established. | 1 inhalation twice per day. | Most children <4 years of age cannot provide sufficient inspiratory flow for adequate lung delivery of DPI. Do not exceed dose shown. |
| MDI 45 mcg/21 mcg | 2 puffs twice per day. | |||
| Budesonide-formoterol | HFA MDI 80 mcg/4.5 mcg | Safety and efficacy not established. | 1 to 2 puffs twice per day. | Onset of formoterol is similar to albuterol. There have been no clinical trials in children ≤4 years of age. Do not exceed dose shown. |
| Mometasone-formoterol | HFA MDI 50 mcg/5 mcg | Safety and efficacy not established. | 2 puffs twice per day. | |
| Systemic glucocorticoids | ||||
| Methylprednisolone | For detail, refer to Lexicomp drug-specific monographs included with UpToDate | 0.25 to 2 mg/kg orally per day or every other day given in the morning. Titrate to the lowest acceptable dose that maintains control. | 0.25 to 2 mg/kg orally per day or every other day given in the morning. Titrate to the lowest acceptable dose that maintains control. | (Applies to all 3 glucocorticoids) Due to their toxic effects, systemic glucocorticoids should be used only rarely for long-term control of asthma (ie, in those few patients with poorly controlled severe persistent asthma despite compliance with maximized ICS and other pharmacologic and preventive therapies). Refer to UpToDate topics on the treatment of persistent asthma in children. The use and dosing of systemic glucocorticoids for the treatment of acute asthma exacerbations is reviewed elsewhere. Refer to UpToDate topics on acute asthma exacerbations in children in the emergency department and inpatient management. |
| Prednisolone | ||||
| Prednisone | ||||
| Long-acting anticholinergic agents | ||||
| Tiotropium | Soft-mist inhaler 1.25 mcg/actuation | Safety and efficacy not established. | 2 inhalations once daily. (Off-label use: 2 inhalations of 2.5 mcg/actuation dose once daily.) | Inhaler is used without a spacer/valved holding chamber. There have been no clinical trials in children ≤4 years of age. |
| Chromones | ||||
| Cromolyn sodium (sodium cromoglycate) | 5 mg/puff CFC free MDI (not available in the United States)◊ | Safety and efficacy not established | 2 puffs 4 times per day. | Less effective than ICS in children. Add-on to ICS is not recommended. Refer to UpToDate topics on the treatment of persistent asthma in children. 4- to 6-week trial may be needed to determine maximum benefit. May cause bronchospasm. Premedication with bronchodilator may be needed. Use of spacer device may substantially decrease amount of drug delivered. Once control is achieved, the frequency of dosing may be reduced. |
| 20 mg/ampule solution for nebulization | 20 mg 4 times per day. Safety and efficacy not established in children aged <2 years. | 20 mg 4 times per day. | ||
| Nedocromil | 2 mg/puff CFC free inhaler (not available in the United States)◊ | Safety and efficacy not established in children aged <6 years. | 2 puffs 4 times per day. | |
| Biologic agents: Refer to separate UpToDate table and topics on biologic therapy for asthma, including omalizumab (anti-IgE) and mepolizumab (anti-IL-5) | ||||
| Methylxanthines | ||||
| Theophylline | Liquids, sustained-release tablets and capsules | Starting dose for patients without risk factors for decreased theophylline clearance approximately 10 mg/kg per day (initial maximum 300 mg per day). Usual maximum following titration:
| Starting dose for patients without risk factors for decreased theophylline clearance approximately 10 mg/kg/day (initial maximum 300 mg per day). Usual maximum following titration:
| Due to risk of toxic effects, requirement of frequent serum concentration monitoring, and significant drug-drug interactions, theophylline is infrequently used. Monitoring and dose adjustment is required to maintain peak serum levels of 5 to 15 mcg/mL at steady-state. For additional information, including approach to dose adjustment, refer to UpToDate topics on theophylline use in asthma. |
