Asthma – Does the steroid matter?

Adults and children present to emergency departments on a regular basis with exacerbation of their condition for a variety of reason.  Anecdotally, the standard treatment for run-of-the-mill asthma is nebs followed by a 5 day prednisone burst.  However, does it really matter which steroid we use?  And would the use of another steroid have advantages over the classical “gold standard” treatment?  Here we will explore some literature that may help change your current practices.

Butler et al. prospectively conducted phone interviews following prescriptions of 161 children discharged from a pediatric emergency department regarding adherence to the prescribed regimen.  They were able to follow up almost 94% of the discharged patients.  They found that prescription fill rates were over 98%.  However, they found slightly more than 1 in 3 caregivers reported not following the complete medication regimen.  Most of them cited concerns about possible side-effects as the reason for not adhering to the regimen.

Lindenauer et al. retrospectively reviewed the charts of over 73,000 patients that were admitted for COPD exacerbation to a non-ICU bed.  Co-founding factors were controlled among the two groups: high-dose IV steroids, low-dose oral steroids.  They defined a treatment failure as mechanical ventilation more than 24 hours after admission, in-hospital death, or re-admission within 30 days for COPD.  They found that low-dose oral steroids were not inferior to high-dose IV steroids.  While this study focused on COPD, the general pathophysiology of COPD and asthma share a lot in common, including most of the treatment modalities.  The take-home point here is that high-dose steroids are probably unnecessary, and IV steroids confer no benefit over oral regimens.

So, let’s take a look at some alternate medication regimens.  Kravitz et al. did an RCT of 2 days of dexamethasone versus 5 days of prednisone for adults with acute asthma exacerbation.  200 patients were randomized to 50mg of prednisone for 5 days or 16 mg of dexamethasone for 2 days.  They found that 90% of the dexamethasone group reported resuming normal daily activities at the 3 day mark compared to only 80% in the prednisone group.  Additionally, they found the bounce-back rate to be the same between the two groups.

Now that we see that dexamethasone in adults is actually more effective in symptom relief than prednisone in adults, how does it perform in children?

Qureshi et al. randomized children 2 to 18 years of age with acute asthma exacerbation presenting to a pediatric emergency department to 5 days of prednisone at 2mg/kg (max 60mg) versus 2 days of dexamethasone at 0.6mg/kg (max 16mg).  Hospitalization rates, relapse rates, and 10-day symptom persistence were equivalent in both groups.  However, more parents reported non-adherence in the prednisone group (4% vs 0.4%) and more missed days of school (20% vs 13%).

Altamimi et al. randomized children ages 2 to 16 years old to a single dose of dexamethasone 0.6mg/kg (max 18mg) in the ED or 5 days of prednisone at 1mg/kg (max 30mg) twice daily for 5 days.  Mean days to patient baseline by way of a standardized Patient Self Assessment Scoring system were equivalent in both groups.

Take home point: One to two days of oral dexamethasone is equal to, if not better, than a prednisone course.  Additionally, treating patients with dexamethasone is likely to result in higher rates of medication adherence. In short, next time you treat a patient acute asthma consider 1-2 days of oral dexamethasone instead.

REFERENCES
Butler et al.  Adherence of pediatric asthma patients with oral corticosteroid prescriptions following pediatric emergency department visit or hospitalization.  Pediatr Emerg Care 2004, 20:11.
Lindenauer et al.  Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease.  JAMA 2010, 303:23.
Kravitz et al.  Two days of dexamethsone versus 5 days of prednisone in the treatment of acute asthma: a randomized controlled trial.  Ann Emerg Med 2011, 58:2.
Qureshi et al.  Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma.  J Pediatr 2001, 139:1.
Altamimi et al.  Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma.  Pediatr Emerg Care 2006, 22:12.
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