One of Two Dose Steroid Regimens for Adult Asthma Exacerbation

One of Two Dose Steroid Regimens for Adult Asthma Exacerbation

March 2019

EMJClub.com


Vignette

It’s a cold, blustery winter day in the local community emergency department where
you’ve been moonlighting. You’ve seen half a dozen patients with Flu A and just as
many viral upper respiratory infections in the three hours you’ve been on shift. Your
next patients is Mr. Z, a thirty-year-old with a history of asthma, who presents with a
runny nose, nonproductive cough, and increased wheezing over the last 2 days. He
has had some mild relief with his home albuterol MDI and is on no other meds. On
exam, he has diffuse expiratory wheezes with an oxygen saturation of 97% on room
air. He is no distress, is speaking in full sentences, and has an otherwise normal
physical exam.

After getting two short duo nebs in the ED he feels much better and has improved
aeration with faint end-expiratory wheezes. His chest x-ray is clear and he would
like to go home. You’ve already decided to give him steroids for this asthma
exacerbation, and remember reading that in children, oral and IM dexamethasone
are equivalent to the usual PO prednisolone, with the benefit that patients require
only 1-2 doses (instead of 5). You wonder if the same holds true for adults (who are
basically just big kids anyway). After sending Mr. Z home with 5 days of prednisone,
you decide to search the literature, wondering if a single dose of dexamethasone (or
equivalent) would have been sufficient…


PICO Question

Population: Adult patients with acute asthma exacerbation being discharged from the emergency department (ED)

Intervention: One or two doses of IM or PO dexamethasone (or equivalent)

Comparison: Five days of PO prednisone

Outcome: Relapse of asthma symptoms, return ED visits, return to normal activities


Search Strategy

PubMed was searched using the terms “asthma AND (dexamethasone OR
methylprednisolone) NOT (children OR pediatric OR paediatric)” limited to clinical
trials (http://tinyurl.com/y3wg28h3). This results in 167 citations, from which 3
relevant studies were chosen. The Cochrane Database of Systematic Reviews was
also searched using the terms “asthma AND corticosteroids), resulting in a
systematic review and meta-analysis that was also included in our discussion.

Articles

Article 1: Kravitz J, Dominici P, UQberg J, Fisher J, Giraldo P. Two days of
dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a
randomized controlled trial. Ann Emerg Med. 2011 Aug;58(2):200-4.
ANSWER KEY

Article 2: 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 Nov;68(5):608-613.
ANSWER KEY

Article 3:  Kirkland SW, Cross E, Campbell S, Villa-Roel C, Rowe BH. Intramuscular
versus oral corticosteroids to reduce relapses following discharge from the
emergency department for acute asthma. Cochrane Database Syst Rev. 2018 Jun
2;6:CD012629.
ANSWER KEY

Article 4: Lahn M, Bijur P, Gallagher EJ. Randomized clinical trial of intramuscular vs oral methylprednisolone in the treatment of asthma exacerbations following
discharge from an emergency department. Chest. 2004 Aug;126(2):362-8.
ANSWER KEY


Bottom Line

Asthma accounts for approximately 2.1 million ED visits annually (Moorman 2012),
with multiple prior studies recommending systemic corticosteroids to prevent
relapse following treatment for an asthma exacerbation. This frequently entails
providing a dose of corticosteroids in the ED followed by a prescription for several
more days worth. Given that up to 28% of patients do not fill prescriptions written
from the ED (Saunders 1987, Thomas 1996), and given the acceptance of single-dose
dexamethasone for asthma exacerbation in children, further evaluation of
alternative, shortened dosing regimens in adults seems warranted.

In 2004, Lahn et al evaluated the use of a single dose of IM methylprednisolone
compared to an 8-day taper of oral methylprednisolone among 180 adults
discharged from the ED following treatment for an asthma exacerbation. They found
no difference in 10-day relapse rates between the IM and PO groups, with a risk
difference of 0.5% (95% CI -9.6% to 10.6%). Twenty-one-day relapse rates were
also similar between the groups. A similar study from 2011 (Kravitz 2011)
comparing two daily doses of oral dexamethasone to a 5-day course of oral
prednisone also found no difference in hospital admission, repeat ED visits, or
primary care visits between the two treatment groups. Patients in the oral
dexamethasone were more likely to return to normal activity within 3 days of ED
visit compared to the prednisone group, with an absolute risk reduction of 10%,
(95% CI 0% to 20%), though it is unclear if this outcome was chosen a priori, or was
the result of data mining following study completion.

A more recent study (Rehrer 2016) compared a single dose of oral dexamethasone
(12 mg) with a 5-day course of oral prednisone. Among 276 patients analyzed,
relapse occurred in 12.1% of patients in the dexamethasone group and 9.8% of the
prednisone group for a risk difference of 2.3% (95% CI -4.1% to 8.6%).
Unfortunately, this study was conducted in a noninferiority design, and the upper
limit of the 95% CI crossed the prespecified noninferiority threshold. While this
study was not able to demonstrate the noninferiority of single-dose, oral dexamethasone, the results suggest that it is as safe and effective as a more prolonged course of prednisone.

A systematic review and meta-analysis looking at single-dose IM steroids versus a
course of oral steroids was also identified (Kirkland 2018). This review included
both pediatric and adult studies, but when looking only at adult studies (n = 5
comprising 559 participants), pooled relapse rates were similar between the groups,
with a relative risk of 0.97 (95% CI 0.71 to 1.33, I2 = 0%). The studies were primarily
limited by lack of reporting.

While none of the research looking at the use of longer acting steroid to treat acute
asthma exacerbations in adults is extremely robust, the bulk of evidence suggests
that a single dose of IM or PO dexamethasone (or methylprednisolone) is as effective
at reducing relapse in this patient population.

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