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Single-Dose Dexamethasone Equals Three Days of Steroids in Children with Acute Asthma

Single-Dose Dexamethasone Equals Three Days of Steroids in Children with Acute Asthma

Clinical Question

In children with acute exacerbation of asthma, is a single dose of corticosteroid as effective as three days of treatment?

Bottom Line

In addition to usual beta-agonist treatment, a single dose of oral dexamethasone is as effective as three days of prednisolone (with less vomiting) in decreasing respiratory symptoms without increasing hospitaliza­tions, follow-up visits, and days lost from school. Additional treatment with a steroid was more common in the group receiving the single dose of dexamethasone. (Level of Evidence = 1b)

Synopsis

These Irish investigators enrolled 226 children (for a total of 245 enrollments; some were enrolled twice) between the ages of two and 16 years with an acute exacerbation of asthma. The children were randomized (concealed allocation unknown) to receive a single dose of oral dexamethasone (0.3 mg per kg) or three days of oral prednisolone (1 mg per kg per day) in addition to usual therapy. None of the patients, their parents, or the investiga­tors were masked to treatment assignment, although the outcome assessor was unaware of treatment at the time of evaluation, which was four days after presentation. The Pediat­ric Respiratory Assessment Measure (PRAM) was used to measure symptoms. It consists of measuring suprasternal and scalene muscle contraction, air entry, wheezing, and oxygen saturation, with a maximum score of 12. After four days, PRAM scores were similar between the two groups (0.91 vs. 0.91). Hospi­tal admission rates were also similar between the two groups, as were days lost from school and parental workdays missed. Return vis­its were similar between the two groups, although more children receiving the single dose required further steroid treatment within the following two weeks (13% vs. 4%). Vomit­ing occurred more often with prednisolone.

Study design: Randomized controlled trial (nonblinded)

Funding source: Foundation

Allocation: Uncertain

Setting: Emergency department

Reference: Cronin JJ, McCoy S, Kennedy U, et al. A randomized trial of single-dose oral dexamethasone versus multidose prednisolone for acute exacerbations of asthma in children who attend the emergency department. Ann Emerg Med. 2016;67(5):593-601.e3.

Single-Dose Dexamethasone an Option for Acute Adult Asthma

Clinical Question

Is a single dose of dexamethasone as effective as five days of prednisone for acute exacerbations of asthma?

Bottom Line

A single dose of 12-mg dexamethasone, which has a lon­ger duration of action than prednisone, is almost as effec­tive as five days of 60-mg prednisone for the prevention of relapse in adults with acute asthma treated in an emer­gency department. It is a reasonable option for treatment in the emergency department, given its fewer adverse effects. In this study, patients who received the single dose also took placebo for four days. Further research is needed to determine whether patients are comfortable with taking just a single dose. (Level of Evidence = 2b)

Synopsis

These investigators enrolled 465 adults younger than 56 years who presented with acute asthma to an emer­gency department and required at least one treatment with a beta agonist. The patients were randomly assigned, using concealed allocation, to receive treatment with prednisone, 60 mg daily, for five days or a single dose of dexamethasone, 12 mg, followed by four days of placebo. Treatment was started in the emergency department. Of the 465 persons initially enrolled, 376 could be evalu­ated; 16 were admitted before leaving the emergency department and 73 could not be contacted (more in the dexamethasone group). Over the subsequent two weeks, 12.1% of the dexamethasone group and 9.8% of the prednisone group had a relapse that required additional treatment (difference = 2.3%; 95% confidence inter­val, −4.1% to 8.6%). This difference did not meet the researchers’ threshold for noninferiority of 8%, mean­ing that treatment with dexamethasone was slightly less effective. The hospitalization rate was low (3%) and did not differ between treatment groups. Adverse effects were more common in the prednisone group.

Study design: Randomized controlled trial (double-blinded)

Funding source: Foundation

Allocation: Concealed

Setting: Emergency department


Reference: Rehrer MW, Liu B, Rodriguez M, Lam J, Alter HJ. A randomized controlled noninferiority trial of single dose of oral dexamethasone versus 5 days of oral prednisone in acute adult asthma. Ann Emerg Med. 2016;68(5):608-613.

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