Titrating steroids on exhaled nitric oxide in children with asthma - A randomized controlled trial

Rationale: Corticosteroids are the antiinflammatory treatment of choice in asthma. Treatment guidelines are mainly symptom-driven but symptoms are not closely related to airway inflammation. The fraction of nitric oxide in exhaled air (F-ENO) is a marker of airway inflammation in asthma. Objective: We evaluated whether titrating steroids on F-ENO improved asthma management in children. Methods: Eighty-five children with atopic asthma, using inhaled steroids, were allocated to a F-ENO group (n = 39) in which treatment decisions were made on both F-ENO and symptoms, or to a symptom group (n = 46) treated on symptoms only. Children were seen eve 3 months over a 1-year period. Measurements: Symptoms were scored during 2 weeks before visits and 4 weeks before the final visit. FeNO was measured at all visits, and airway hyperresponsiveness and FEV1 were measured at the start and end of the study. Primary endpoint was cumulative steroid dose. Results: Changes in steroid dose from baseline did not differ between groups. In the F-ENO group, hyperresponsiveness improved more than in the symptom group (2.5 vs. 1.1 doubling dose, p = 0.04). FEV1 in the F-ENO group improved, and the change in FEV1 was not significantly different between groups. The F-ENO group had 8 severe exacerbations versus 18 in the symptom group. The change in symptom scores did not differ between groups. F-ENO increased in the symptom group; the change in F-ENO from baseline differed between groups (p = 0.02). Conclusion: In children with asthma, 1 year of steroid titration on F-ENO did not result in higher steroid doses and did improve airway hyperresponsiveness and inflammation.