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Asthma is the commonest chronic illness of childhood.1 As prevention is impossible, management is aimed at controlling symptoms and reducing future risk. Although inhaled corticosteroids (ICS) are highly effective in controlling asthma, some children will continue to have symptoms or exacerbations2 and may require more treatment. The principal ‘step-up’ options include adding either an inhaled long-acting β-agonist (LABA) or an oral leukotriene receptor antagonist (LTRA) to ICS or using high-dose ICS. The evidence base informing this decision is weak in children, and controversy persists.3 Guidelines suggest that for children aged 5 years or older, LABA addition is the best ‘first-choice’ option,1 although recent safely concerns have lead the FDA to make different recommendations.4 This timely study aimed to compare the efficiency of these three step-up options in children who remained symptomatic despite ICS (fluticasone 100 μg twice daily). It also aimed to identify phenotypic or genotypic factors predicting a differential response to treatment. …
Competing interests MT received consulting fees from MSD, Schering, Novartis and GSK and received honoraria from Altana, Astra Zeneca, Boehringer Inglehiem, GSK, MSD, Merck Respiratory, Schering-Plough and Teva. He also received funding for research projects from GSK, MSD, Astra Zeneca and currently holds a research fellowship from Asthma UK.