| Summary: | Maintenance use of short-acting adrenergic agents can cause tachyphylaxis, increased non-specific bronchial hyperreactivity, poorer clinical control, a worsened late allergic reaction and possibly an increased risk of death; therefore, 'as needed' use is preferable. The choice of a first line anti-inflammatory drug, between inhaled corticosteroids and non-steroidal drugs (cromolyn sodium or nedocromil sodium), has to be made considering their risk–benefit ratio. Although in severe patients the efficacy of inhaled corticosteroids is clearly superior to that of cromolyn, in mild-to-moderate patients the efficacy is comparable. In terms of safety, non-steroidal drugs have a better safety profile than inhaled corticosteroids, which can cause growth suppression even at regular doses, especially in mild-to-moderate patients. Although some investigators have raised the possibility of irreversible airway obstruction if treatment with inhaled corticosteroids is delayed, studies by my group and others, using non-steroidal drugs as first line, have not confirmed that suspicion. In conclusion, a step-wise approach in children is still justified, starting with non-steroidal drugs (cromolyn sodium or nedocromil sodium) in mild persistent asthma and using inhaled corticosteroids only in patients poorly controlled by the non-steroidal drugs.
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