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Piling Pelion upon Ossa: surely we already have enough non-evidence based ways of treating acute asthma?
  1. Mark L Levy1,
  2. Louise Fleming2,3,
  3. Stephen Goldring4,
  4. Andy Bush5,6
  1. 1 Locum General Practitioner, London, UK
  2. 2 Respiratory Paediatrics, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  3. 3 Respiratory Paediatrics, Imperial College London National Heart and Lung Institute, London, UK
  4. 4 Paediatrics, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
  5. 5 Paediatric Respiratory Mediicne, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  6. 6 Paediatric Respiratory Medicine, National Heart and Lung Institute Division of Respiratory Science, London, UK
  1. Correspondence to Dr Mark L Levy, Locum General Practitioner, London HA3 0YX, UK; mark-levy{at}

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The UK is the sick man of Europe in terms of the management of asthma in children and young people (CYP). Only one of the 28 CYP deaths assessed in the National Review of Asthma Deaths was adequately managed. Clearly, we are incapable of following established, evidence-based guidelines (

Unfortunately, the response appears to be not to follow what works, but to switch to poorly evidenced strategies.

One example is the use of very high, unlicenced dose ‘salbutamol weaning plans’ where children are prescribed 10 puffs (1000 μg) of salbutamol every 4 hours in reducing doses for up to 5 days (ie, up to 6000 μg salbutamol a day) after hospital or emergency department discharge. This wholly non-evidenced-based practice, which may mask the need for systemic corticosteroids, has come in by the back door despite clear-cut evidence of harm from excessive doses of β-2 agonist and evidence from adult studies detailed in the Global Initiative on Asthma (GINA) that as-needed bronchodilator shortens hospital stay for an acute attack compared with regular administration.1

More recently, some UK paediatric departments are now discharging CYP after acute treatment for asthma/wheezing attacks with a single predischarge dose of dexamethasone instead of guideline-directed advice of daily prednisolone for 3 or more days ( The rationale is that dexamethasone carries a lower risk of vomiting, and is cheaper and more convenient. However, this new practice has only a weak evidence base and is justified on heterogeneous studies of low or very low quality in meta-analyses.

Keeney …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests MLL: reports speakers fees or fees for expert consultation from Clement Clarke International, Teva, AstraZeneca, Chiesi, Respiri, Trudel Pharmaceuticals, Soar Beyond, Orion Pharmaceuticals, Napp Pharmaceuticals, National Services for Health Improvement (a company providing services for general practices, ie, nurse asthma reviews), Novartis Pharmaceuticals and GlaxoSmithKlein; grants from Consorcio Futuro in Richerce and non-financial support from Asthma and COPD (Joint) Lead for Whole Systems Integrated Care (WSIC) NorthWest London and the Global Initiative on Asthma (GINA) outside the submitted work. LF: reports grants from Asthma UK, and speakers fees or fees for expert consultation from Teva, AstraZeneca, Sanofi, Respiri, Novartis; all fees paid direct to her institution and outside the submitted work.

  • Provenance and peer review Commissioned; externally peer reviewed.

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