Comparative response to pharmacological management of asthma in overweight/obese children versus their counterparts: a systematic review and call for data.

BACKGROUND

Obese children with asthma experience higher morbidity than their counterparts; whether different treatments should be considered remains to be clarified.

OBJECTIVE

To explore the potential group differences in the treatment response to any asthma medications between overweight/obese and normal/underweight children.

METHODS

We systematically reviewed case-control, cohort studies and randomised controlled trials (RCTs) examining treatment effects by weight status, identified in four bibliographic databases from inception until January 2025. A narrative synthesis was presented because a meta-analysis could not be conducted due to methodological issues.

RESULTS

Nine studies (one RCT, five post hoc analyses of RCTs, two cohorts, and one post hoc analysis of a case-control study), including 7089 children (33.9% overweight/obese), met the inclusion criteria. Pharmacological treatment pertained to step 1-2 (n=1), step 2 (n=3), step 3 (n=2), step 5 (n=2), and bronchodilator-response (n=1). Compared with normal weight, step 1-2 showed a trend toward reduced inhaled corticosteroid (ICS) efficiency in minimising symptom days in overweight/obese preschoolers. Regarding step 2 monotherapy, overweight/obese children may benefit as much (or more) from nedocromil or leukotriene receptor antagonist (LTRA) than from ICS. In step 3, adding LTRA (versus placebo) to ICS monotherapy was more effective, whereas higher-dose ICS monotherapy was less effective than LTRA or long-acting β2-agonist (LABA) combination therapy in obese than normal-weight children; adding LABA appears equally effective across weight groups. A similar or better response to omalizumab was observed in obese compared to nonobese children.

CONCLUSION

While no firm recommendations could be made regarding potential differential treatment responses, the superiority of ICS monotherapy or step-up therapy compared to other controllers appears lost in overweight/obese children.