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Lee B, Turner S, Borland M, Csonka P, Grigg J, Guilbert TW, Jartti T, Oommen A, Twynam-Perkins J, Lewis S, Cunningham S. Efficacy of oral corticosteroids for acute preschool wheeze: a systematic review and individual participant data meta-analysis of randomised clinical trials. THE LANCET. RESPIRATORY MEDICINE 2024; 12:444-456. [PMID: 38527486 DOI: 10.1016/s2213-2600(24)00041-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Oral corticosteroids are commonly used for acute preschool wheeze, although there is conflicting evidence of their benefit. We assessed the clinical efficacy of oral corticosteroids by means of a systematic review and individual participant data (IPD) meta-analysis. METHODS In this systematic review with IPD meta-analysis, we systematically searched eight databases (PubMed, Ovid Embase, CINAHLplus, CENTRAL, ClinicalTrials.gov, EudraCT, EU Clinical Trials Register, WHO Clinical Trials Registry) for randomised clinical trials published from Jan 1, 1994, to June 30, 2020, comparing oral corticosteroids with placebo in children aged 12 to 71 months with acute preschool wheeze in any setting based on the Population, Intervention, Comparison, Outcomes framework. We contacted principal investigators of eligible studies to obtain deidentified individual patient data. The primary outcome was change in wheezing severity score (WSS). A key secondary outcome length of hospital stay. We also calculated a pooled estimate of six commonly reported adverse events in the follow-up period of IPD datasets. One-stage and two-stage meta-analyses employing a random-effects model were used. This study is registered with PROSPERO, CRD42020193958. FINDINGS We identified 16 102 studies published between Jan 1, 1994, and June 30, 2020, from which there were 12 eligible trials after deduplication and screening. We obtained individual data from seven trials comprising 2172 children, with 1728 children in the eligible IPD age range; 853 (49·4%) received oral corticosteroids (544 [63·8%] male and 309 [36·2%] female) and 875 (50·6%) received placebo (583 [66·6%] male and 292 [33·4%] female). Compared with placebo, a greater change in WSS at 4 h was seen in the oral corticosteroids group (mean difference -0·31 [95% CI -0·38 to -0·24]; p=0·011) but not 12 h (-0·02 [-0·17 to 0·14]; p=0·68), with low heterogeneity between studies (I2=0%; τ2<0·001). Length of hospital stay was significantly reduced in the oral corticosteroids group (-3·18 h [-4·43 to -1·93]; p=0·0021; I2=0%; τ2<0·001). Subgroup analyses showed that this reduction was greatest in those with a history of wheezing or asthma (-4·54 h [-5·57 to -3·52]; pinteraction=0·0007). Adverse events were infrequently reported (four of seven datasets), but oral corticosteroids were associated with an increased risk of vomiting (odds ratio 2·27 [95% CI 0·87 to 5·88]; τ2<0·001). Most datasets (six of seven) had a low risk of bias. INTERPRETATION Oral corticosteroids reduce WSS at 4 h and length of hospital stay in children with acute preschool wheeze. In those with a history of previous wheeze or asthma, oral corticosteroids provide a potentially clinically relevant effect on length of hospital stay. FUNDING Asthma UK Centre for Applied Research.
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Affiliation(s)
- Bohee Lee
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.
| | - Steve Turner
- Royal Aberdeen Children's Hospital, NHS Grampian, Aberdeen, UK
| | - Meredith Borland
- Perth Children's Hospital Emergency Department and Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, WA, Australia
| | - Péter Csonka
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Terveystalo Healthcare, Tampere, Finland
| | - Jonathan Grigg
- Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | - Theresa W Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland; PEDEGO Research Unit, University of Oulu, Oulu, Finland; Department of Pediatrics, Oulu University Hospital, Oulu, Finland
| | - Abraham Oommen
- Department of Paediatrics, Milton Keynes University Hospital NHS Trust, Milton Keynes, UK
| | - Jonathan Twynam-Perkins
- Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK; Department of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Steff Lewis
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Usher Institute, and Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Steve Cunningham
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Kwong CG, Bacharier LB. Management of Asthma in the Preschool Child. Immunol Allergy Clin North Am 2019; 39:177-190. [PMID: 30954169 DOI: 10.1016/j.iac.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The management of asthma in the preschool population is challenging because disease phenotypes are heterogeneous and evolving. Available therapies aimed at preventing persistent symptoms and recurrent exacerbations include inhaled corticosteroids and leukotriene receptor antagonists; episodic use of inhaled corticosteroids and azithromycin may result in a decrease in exacerbations among children with intermittent disease. This article reviews an approach using patient characteristics for selecting initial treatment approaches based on disease phenotype, such as symptom patterns or evidence of atopic markers. Evidence for and against the use of oral corticosteroids during acute episodes and barriers to adherence and effective treatment are discussed.
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Affiliation(s)
- Christina G Kwong
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Campus Box 8116, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Campus Box 8116, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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