A single dose of intramuscularly administered dexamethasone acetate is as effective as oral prednisone to treat asthma exacerbations in young children

Impact of a discharge prescription for dexamethasone on outcomes of children treated in the emergency department for acute asthma exacerbations

OBJECTIVE

To evaluate dexamethasone prescribing practices, patient adherence, and outcomes by dosing regimen in children with acute asthma discharged from the emergency department (ED).

STUDY DESIGN

Prospective study of children 2-18 years treated with dexamethasone for acute asthma prior to discharge from an urban, tertiary care ED between 2018 and 2022. Demographics, clinical characteristics, ED treatment, and discharge prescriptions were collected via chart review. The exposure was discharge prescription (additional dose) versus no discharge prescription for dexamethasone. The primary outcome was treatment failure, defined as return ED visit, unplanned primary care visit, and/or ongoing bronchodilator use. Secondary outcomes included medication adherence, symptom persistence, quality-of-life, and school/work absenteeism. Outcomes were assessed by telephone 7-10 days after discharge.

RESULTS

564 subjects were enrolled; 338 caregivers (60%) completed follow-up. Children were a median age 7 years, 30% Black or African American, 49% Hispanic, and 79% had public insurance. A discharge prescription for dexamethasone was written for 482 (86%) children and was significantly associated with exacerbation severity, number of combined albuterol/ipratropium treatments, and longer length of stay. There was no difference in treatment failure between the discharge prescription and no discharge prescription groups (RR 0.87; 0.67, 1.12), including after adjusting for potential confounders; there was no difference between groups in secondary outcomes.

CONCLUSIONS

Prescription for an additional dexamethasone dose was not associated with reduced treatment failure or improved outcomes for children with acute asthma discharged from the ED. Single, ED-dose of dexamethasone prior to discharge may be sufficient for children with mild to moderate asthma exacerbations.

Prednisolone versus cyclosporine as initial treatment for Kawasaki disease

BACKGROUND

Several studies have demonstrated the efficacy of prednisolone and cyclosporine as initial combination treatments for the prevention of coronary artery abnormalities (CAA) in patients with Kawasaki disease. However, whether prednisolone or cyclosporine results in superior clinical outcomes is unknown. Thus, this study aimed to compare the outcomes of these two treatments.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we identified patients with Kawasaki disease who had received prednisolone or cyclosporine in addition to initial intravenous immunoglobulin treatment between April 2014 and March 2021. The primary outcome was the proportion of CAA; secondary outcomes included intravenous immunoglobulin resistance, medical costs, and length of hospital stay. Propensity score matching was conducted to compare outcomes between the two groups.

RESULTS

We identified 6288 patients with Kawasaki disease who had received prednisolone (n = 6147) or cyclosporine (n = 141) as an initial treatment in combination with intravenous immunoglobulin. Four-to-one propensity score-matched analysis demonstrated no significant difference in the proportion of CAA (0.7% vs. 2.8%; p = 0.098), intravenous immunoglobulin resistance, or medical costs between the treatment groups. The length of hospital stay was significantly longer in the prednisolone group (14 vs. 11 days, p < 0.001).

CONCLUSIONS

Prednisolone and cyclosporine used in the initial combination treatment for Kawasaki disease showed similar clinical outcomes regarding the risk of CAA, intravenous immunoglobulin resistance, and medical costs, whereas the length of hospital stay was longer in the prednisolone group than in the cyclosporine group.

Comparative effectiveness of oral dexamethasone vs. oral prednisolone for acute exacerbation of asthma: A randomized control trial

Background:

Acute exacerbation of asthma is a common condition leading to emergency visits. Prednisolone is a commonly prescribed drug in the standard management of acute exacerbation of asthma along with other drugs. This study was planned to see the efficacy of oral dexamethasone when compared with oral prednisolone in the management of acute exacerbation of asthma.

Methods:

A single-center pilot study in the form of randomized control trial was done by recruiting children aged 2–14 years diagnosed with acute asthma exacerbation with mild to moderate severity. A total of 88 patients received oral dexamethasone (0.3 mg/kg) in two doses 24 h apart, which was compared with 87 patients who received oral prednisolone (1 mg/kg) in two divided doses 12 h apart for 5 days. The patients were assessed at the time of admission (zero hour), at 4^th hour, and on the 5^th day by various parameters such as respiratory rate, use of accessory muscles, Pediatric Respiratory Assessment Measure (PRAM) score, peak expiratory flow rate (PEFR), 6-h admission stay, and rate of hospital admission.

Results:

Baseline demographic profile, clinical characteristics, comorbidities, indoor pollution, and use of Metered Dose Inhaler (MDI) among the two study groups were comparable. Six-hour emergency stay and rate of admission were significantly lower in the dexamethasone group (P < 0.05). Improvement in PRAM score, PEFR, use of accessory muscles, and respiratory rate was also better in dexamethasone group at the 4^th hour and 5^th day (P < 0.05). In addition, oral dexamethasone was shown to have less incidence of vomiting/gastritis than prednisolone (P < 0.05).

Conclusion:

Oral dexamethasone can be considered a reliable and better option as compared with prednisolone due to its faster action and minimal side effects.

Dexamethasone Versus Prednisone or Prednisolone for Acute Pediatric Asthma Exacerbations in the Emergency Department: A Meta-Analysis

OBJECTIVE

This study evaluates the efficacy and tolerability of dexamethasone (DEX) as an alternative to prednisone/prednisolone (PRED) for the treatment of pediatric asthma exacerbations in emergency department (ED).

METHODS

Fixed-effects meta-analyses of selected endpoints were performed by using data taken from relevant studies identified by following a priori eligibility criteria after a comprehensive literature search in several electronic databases.

RESULTS

Data from 10 studies (3208 pediatric asthma patients [1616 DEX treated and 1592 PRED treated], 4.77 years [95% confidence interval, 3.80-5.56 years], 63% [57.76%-62.68%] males) were used. Risk of vomiting drug was significantly lower in DEX group than in PRED group (risk ratio, 0.29 [0.18-0.48]; P ˂ 0.00001). Emergency department stay between DEX and PRED treated patients was statistically different (0.16 [0.03-0.40] hours; P = 0.02) but may not be clinically meaningful. The number of β-agonist therapies received by DEX- and PRED-treated patients was similar. Treatments with both DEX and PRED were associated with improvement in asthma status assessment scores, and there was no significant difference between the groups. There were also no differences between the groups in hospitalization rate, ED revisit rate, and hospital admission rate after relapse.

CONCLUSIONS

Dexamethasone is a suitable alternative to PRED for the treatment of pediatric asthma exacerbation in ED.

Dexamethasone Versus Prednisone in Children Hospitalized for Acute Asthma Exacerbations

BACKGROUND AND OBJECTIVES

Extensive literature supports using dexamethasone (DEX) in children presenting to the emergency department (ED) with mild-to-moderate asthma exacerbations; however, only limited studies have assessed this in hospitalized children. In this study, we evaluate the outcomes of DEX versus prednisone/prednisolone (PRED) use in children hospitalized for mild-to-moderate asthma exacerbations.

METHODS

This multisite retrospective cohort study included children between 3 and 21 years of age hospitalized to a tertiary care children's hospital system between January 1, 2013, and December 31, 2017, with a primary discharge diagnosis of acute asthma exacerbation or status asthmaticus. Primary study outcome was mean hospital length of stay (LOS). Secondary outcomes included PICU transfers during initial hospitalization and ED revisits and hospital readmissions within 10 days after discharge. Generalized linear models were used to model logged LOS as a function of steroid and demographic and clinical covariates. The analysis was stratified by initial steroid timing.

RESULTS

Of the 1410 children included, 981 received only DEX and 429 received only PRED. For children who started oral steroids after hospital arrival, DEX cohort had a significantly shorter adjusted mean hospital LOS (DEX 24.43 hours versus PRED 29.38 hours; P = .03). For children who started oral steroids before hospital arrival, LOS did not significantly differ (DEX 26.72 hours versus PRED 25.20 hours; P = .45). Rates of PICU transfers, ED revisits, and hospital readmissions were uncommon events.

CONCLUSION

Children hospitalized with mild-to-moderate asthma exacerbations have significantly shorter hospital LOS when starting DEX rather than PRED on admission.

Dexamethasone Versus Prednisone for Pediatric Acute Asthma Exacerbations: Specialists' Practice Patterns

BACKGROUND AND OBJECTIVE

Dexamethasone has emerged as a viable alternative to prednisone in the treatment of pediatric acute asthma exacerbations, with the potential for improved compliance secondary to decreased frequency of dosing, improved taste, and decreased cost. The objective of this study is to identify whether providers are prescribing dexamethasone for pediatric acute asthma exacerbations. Secondary objectives are to describe variation in practice between different specialties and to identify the commonly used dosing and frequency for dexamethasone.

METHODS

We conducted a cross-sectional, descriptive study with an anonymous, web-based survey (surveymonkey.com). The survey population included all fellowship program directors listed on FRIEDA Online for pediatric emergency medicine, pediatric pulmonology, and allergy and immunology, and emergency medicine residency directors through the Council of Emergency Medicine Residency Directors listserv. Program directors were contacted via e-mail up to 5 times for 3 months.

RESULTS

Overall, 300 respondents (70% of the program directors) completed the survey. Response rates by specialty varied from 60% to 94%. One third of providers are using dexamethasone, whereas just more than half of providers (51%) are prescribing a 5-day prednisone course. The preferred maximum dose for dexamethasone is 10 mg (45%), with 82% using a dose of 0.6 mg/kg.Pediatric emergency medicine fellowship directors demonstrated a preference for dexamethasone (59%). Prednisone is favored by emergency medicine (56%), pediatric pulmonology (89%), and allergy and immunology (93%) program directors.

CONCLUSIONS

Although most pediatric emergency medicine academic physicians have transitioned to using dexamethasone to treat acute pediatric asthma exacerbations, other specialties continue to favor prednisone.

Emergency department treatment of asthma in children: A review

Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life-threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.

Dexamethasone or prednisolone for asthma exacerbations in children: A cost-effectiveness analysis

OBJECTIVES

Although a short course (ie, 3 to 5 days) of orally administered prednisolone is a common and widely accepted practice among clinicians for administering systemic corticosteroids in pediatric acute asthma, oral dexamethasone for 1 to 2 days is an attractive alternative to prednisolone due to its better palatability and compliance. However, a cost-effectiveness analysis regarding the use of dexamethasone compared to prednisolone is not sufficient, especially in lower- and middle-income countries. The objective of this study was to analyze the cost-effectiveness of prednisolone vs oral dexamethasone for treating pediatric asthma exacerbations.

METHODS

Using a decision-analysis model, we analyzed the cost-effectiveness of prednisolone vs oral dexamethasone for treating acute pediatric asthma. Effectiveness parameters were derived from a systematic review of the published literature. Data for costs were acquired from hospital accounts and from an official national database, the national manual of drug prices in Colombia. The study was carried out from a Colombian third-party payer perspective. The principal outcome of the model was the avoidance of hospitalization.

RESULTS

The base-case analysis showed that compared to dexamethasone, administering prednisolone was associated with lower overall treatment costs (US$93.97 vs US$104.91 mean cost per patient) without a significant difference in the probability of hospitalization avoided (.9108 vs .9108).

CONCLUSIONS

The present study shows that in Colombia, a middle-income country, compared with oral dexamethasone, the use of prednisolone for treating acute pediatric asthma is cost-effective, yielding a similar probability of hospitalization at lesser overall costs.

Oral Dexamethasone vs. Oral Prednisone for Children With Acute Asthma Exacerbations: A Systematic Review and Meta-Analysis

Background: This systematic review and meta-analysis was conducted to compare relapse rates and adverse effects with oral dexamethasone vs. oral prednisone for acute asthma exacerbations in pediatric patients. Methods: A computerized literature search of PubMed, Embase, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google scholar databases was carried out till 1st August 2019. Six Randomized controlled trials (RCTs) and 1 quasi-RCT were included. Dosage of dexamethasone and prednisone varied across studies. Studies were grouped based on the follow-up period and duration of dexamethasone administration. Results: There was no significant difference in the relapse rate between dexamethasone and prednisone at 1-5 days (RR 1.46, 95%CI 0.69-3.7, P = 0.32; I 2 = 0%) and 10-15 days of follow up (RR 1.16, 95%CI 0.80-1.68, P = 0.44; I 2 = 0%). Pooled analysis found no significant difference in relapse rates with 1-day (RR 1.15, 95%CI 0.68-1.95, P = 0.60; I 2 = 0%) and 2-day dosage of dexamethasone (RR 1.25, 95%CI 0.82-1.92, P = 0.30; I 2 = 0%) compared to prednisone. Hospital readmission rates after initial discharge were not significantly different between the two drugs (RR 1.49, 95%CI 0.56-4.01, P = 0.43; I 2 = 0%). Frequency of vomiting at ED (RR 0.21, 95%CI 0.05-0.96, P = 0.04; I 2 = 50%) and at home (RR 0.42, 95%CI 0.25-0.69, P = 0.0007; I 2 = 0%) was significantly higher with prednisone as compared to dexamethasone. Conclusion: While our results indicate that both dexamethasone and prednisone have similar relapse rates when used for acute asthmatic exacerbations, strong conclusions cannot be drawn due to paucity of large scale RCTs and limited quality of evidence. Dexamethasone is however associated with lower incidence of vomiting as compared to prednisone. Further homogenous RCTs are needed to provide robust evidence on this topic.

Safety of corticosteroids in young children with acute respiratory conditions: a systematic review and meta-analysis

OBJECTIVE

Adverse events (AEs) associated with short-term corticosteroid use for respiratory conditions in young children.

DESIGN

Systematic review of primary studies.

DATA SOURCES

Medline, Cochrane CENTRAL, Embase and regulatory agencies were searched September 2014; search was updated in 2017.

ELIGIBILITY CRITERIA

Children <6 years with acute respiratory condition, given inhaled (high-dose) or systemic corticosteroids up to 14 days.

DATA EXTRACTION AND SYNTHESIS

One reviewer extracted with another reviewer verifying data. Study selection and methodological quality (McHarm scale) involved duplicate independent reviews. We extracted AEs reported by study authors and used a categorisation model by organ systems. Meta-analyses used Peto ORs (pORs) and DerSimonian Laird inverse variance method utilising Mantel-Haenszel Q statistic, with 95% CI. Subgroup analyses were conducted for respiratory condition and dose.

RESULTS

Eighty-five studies (11 505 children) were included; 68 were randomised trials. Methodological quality was poor overall due to lack of assessment and inadequate reporting of AEs. Meta-analysis (six studies; n=1373) found fewer cases of vomiting comparing oral dexamethasone with prednisone (pOR 0.29, 95% CI 0.17 to 0.48; I2=0%). The mean difference in change-from-baseline height after one year between inhaled corticosteroid and placebo was 0.10 cm (two studies, n=268; 95% CI -0.47 to 0.67). Results from five studies with heterogeneous interventions, comparators and measurements were not pooled; one study found a smaller mean change in height z-score with recurrent high-dose inhaled fluticasone over one year. No significant differences were found comparing systemic or inhaled corticosteroid with placebo, or between corticosteroids, for other AEs; CIs around estimates were often wide, due to small samples and few events.

CONCLUSIONS

Evidence suggests that short-term high-dose inhaled or systemic corticosteroids use is not associated with an increase in AEs across organ systems. Uncertainties remain, particularly for recurrent use and growth outcomes, due to low study quality, poor reporting and imprecision.

Dexamethasone Associated With Significantly Shorter Length of Hospital Stay Compared With a Prednisolone-Based Regimen in Pediatric Patients With Mild to Moderate Acute Asthma Exacerbations

A retrospective chart review was done to evaluate the efficacy of a course of dexamethasone for pediatric patients hospitalized with a mild to moderate acute asthma exacerbation compared with a prednisone-based regimen. Patients were identified based on International Classification of Diseases (ICD-9 and ICD-10) discharge diagnosis codes for asthma and cross-referenced with pharmacy dispense reports during the study period of June 2011 to January 2016. Baseline characteristics were similar among the 2 groups. The median length of hospital stay in the dexamethasone and prednisolone groups were 1.31 and 1.75 days, respectively, with a hazard ratio of 2.5 (95% confidence interval - 2.1-3.1), P < .001. After accounting for significant confounding variables, the difference in length of stay remained significantly longer in the prednisolone group with a hazard ratio of 1.8 (95% confidence interval = 1.4-2.3), P < .001. A course of dexamethasone is associated with a significantly shorter length of stay for mild to moderate asthma exacerbations compared with a prednisone-based regimen.

Outcomes for Pediatric Asthmatic Inpatients After Implementation of an Emergency Department Dexamethasone Treatment Protocol

OBJECTIVES

Evidence supports using dexamethasone for mild-to-moderate asthma exacerbations in the emergency department, but the effectiveness of dexamethasone versus prednisone for asthmatic patients who are hospitalized is unclear. Our aim was to compare outcomes for inpatients before and after our emergency department's adoption of dexamethasone for the treatment of acute asthma exacerbations.

METHODS

In this single-center retrospective cohort study, we employed interrupted time series analyses to control for secular trends while evaluating our outcomes of length of stay, total inflation-adjusted hospital charges, and ICU transfer rates for patients admitted with asthma.

RESULTS

Data were analyzed over 36 months (January 2014-April 2017) and included 1015 subjects (606 in the preprotocol change [pre-PC] group and 409 in the postprotocol change [post-PC] group). In the pre-PC group, prednisone only was used in 96% of subjects. In the post-PC group, prednisone only was used in 7% of subjects, dexamethasone in 65% of subjects, and a combination of the 2 steroids in 28% of subjects. Controlling for other variables in the interrupted time series model, we found no significant immediate differences between the pre-PC and post-PC periods for the outcomes of length of stay (P = .68), total charges (P = .66), and ICU transfers (P = .98). The rate of ICU transfers was stable pre-PC and increased by 10% (95% confidence interval: 2%-19%) per month (odds ratio = 1.10; 95% confidence interval: 1.02-1.19; P = .02) in the post-PC period.

CONCLUSIONS

After dexamethasone replaced prednisone as the most commonly prescribed steroid type for inpatients with asthma at our institution, we found no immediate changes in outcomes for asthmatic patients who were hospitalized but an upward trend in ICU transfers.

Dexamethasone versus prednisone for children receiving asthma treatment in the paediatric inpatient population: protocol for a feasibility randomised controlled trial

INTRODUCTION

Asthma exacerbations are a leading cause of paediatric hospitalisations. Corticosteroids are key in the treatment of asthma exacerbations. Most current corticosteroids treatment regimens for children admitted with asthma exacerbation consist of a 5-day course of prednisone or prednisolone. However, these medications are associated with poor taste and significant vomiting, resulting in poor compliance with the treatment course. While some centres already use a short course of dexamethasone for treating children hospitalised with asthma, there is no evidence to support this practice in the inpatient population.

METHODS AND ANALYSIS

This single-site, pragmatic, feasibility randomised controlled trial will determine the feasibility of a non-inferiority trial, comparing two treatment regimens for children admitted to the hospital and receiving asthma treatment. Children 18 months to 17 years presenting to a Canadian tertiary care centre will be randomised to receive either a short course of dexamethasone or a longer course of prednisone/prednisolone once admitted to the inpatient units. The primary clinical outcome for this feasibility study will be readmission to hospital or repeat emergency department visits, or unplanned visits to primary healthcare providers for asthma symptoms within 4 weeks of hospital discharge. Feasibility outcomes will include recruitment and allocation success, compliance with study procedures, retention rate, and safety and tolerability of study medications. We plan on recruiting 51 children, and between-group comparisons of the clinical outcome will be conducted to gain insights on probable effect sizes.

ETHICS AND DISSEMINATION

Research Ethics Board approval has been obtained for this study. The results of this study will inform a multisite trial comparing prednisone/prednisolone to dexamethasone in inpatient asthma treatment, which will have the potential to improve the delivery of asthma care, by improving compliance with a mainstay of treatment. Results will be disseminated through peer-reviewed publications, organisations and meetings.

TRIAL REGISTRATION NUMBER

NCT03133897; Pre-results.

Direct Observed Therapy of Inhaled Corticosteroids for Asthma at School or Daycare

Background: Poor adherence with inhaled corticosteroid (ICS) medication is common in the pediatric population and can result in poor asthma control with increased frequency of asthma-related complications. The purpose of this study was to determine whether or not the initiation of ICS administration twice per day at school/daycare in patients with poor medication adherence at home improves asthma health care outcomes. Methods: We retrospectively selected patients followed by our Pediatric Pulmonology Clinic who had poorly controlled asthma and had been assigned to receive ICS twice daily at school/daycare due to poor adherence with ICS therapy. We analyzed the number of short courses of oral corticosteroids, hospital admissions, emergency department visits, and intramuscular methylprednisolone administrations for asthma exacerbations for the year before and after the intervention. The Wilcoxon signed rank test with continuity correction was used in the primary analysis. Results: Forty-nine patients who met the inclusion criteria were identified, but only 40 actually started the intervention. The number of oral corticosteroid courses per year decreased from 1.35 ± 1.1 before the intervention to 0.68 ± 1.2 (P = 0.008) postintervention, hospital admissions per year decreased from 0.45 ± 0.7 to 0.10 ± 0.3 (P = 0.006), emergency department visits per year decreased from 0.55 ± 0.8 to 0.28 ± 0.6 (P = 0.084), and intramuscular repository methylprednisolone injections per year for asthma exacerbations decreased from 0.20 ± 0.4 to 0.10 ± 0.3 (P = 0.23). Conclusion: These results indicate that school/daycare administration of ICS may be an effective option to improve indicators of asthma exacerbations in children with poor adherence to ICS at home.

Two regimens of dexamethasone versus prednisolone for acute exacerbations in asthmatic Egyptian children

Introduction

Asthma is one of the most prevalent chronic respiratory diseases, which often leads to an emergency department visit. Prednisolone is the most commonly used corticosteroid in treatment of asthma exacerbation. Oral dexamethasone demonstrates bioavailability similar to that of oral prednisolone but has a longer half-life.

Objective

To evaluate in adouble-blind, randomised clinical trial the efficacy of different doses of dexamethasone versus prednisolone in controlling asthma exacerbations in children.

Methods

We recruited 60 patients with asthma exacerbation, aged 2-11 years. Participants were randomly divided into three groups (20 patients each). Group I received a single dose of oral dexamethasone 0.3 mg/kg (maximum 12 mg), group II received 0.6 mg/kg/day of oral dexamethasone for 2 days (maximum 16 mg/day) and group III received 1.5 mg/kg/day oral prednisolone for 5 days (maximum 60 mg/day). Our primary outcomes were changes in Paediatric Respiratory Assessment Measure (PRAM), eosinophilic count and serum immunoglobulin E on day 5. Secondary endpoints were reporting any adverse effects and relapse rate during the 5 days. After 30 days, the Asthma Therapy Assessment Questionnaire (ATAQ) was given to the parents of the recruited patients.

Results

Among the three study groups, there was a highly statistically significant difference in IgE level, saturated oxygen, peak expiratory flow, forced expiratory volume in 1 s/forced vital capacity, PRAM and Modified Pulmonary Index Score; however, the eosinophilic count was significantly lower within the same group. Vomiting, gastrointestinal tract cramps, ATAQ and relapse rate showed a non-statistically significant difference.

Conclusion

Single-dose dexamethasone was at least as effective as 5-day course of prednisolone in controlling asthma, while dexamethasone for 2 days was non-inferior to 5 days of prednisolone in children with asthma exacerbation.

Evaluating the effectiveness of systemic corticosteroids to mitigate relapse in children assessed and treated for acute asthma: A network meta-analysis

OBJECTIVE

The objective of this systematic review was to explore the effectiveness of various systemic corticosteroid (SCS) regimens to mitigate relapse in children with asthma discharged from an acute care setting.

DATA SOURCES

Medline, EMBASE, Global Health, International Pharmaceutical Abstracts, EMB ALL, CINAHL, SCOPUS, Proquest Dissertations and Theses Global, and LILACS were searched using controlled vocabulary and key words. Additional citations were searched via clinical trial registries, Google Scholar, bibliographies, a SCOPUS forward search of a sentinel paper, and hand searching conference abstracts.

STUDY SELECTION

No limitations based on language, publication status, or year of publication were applied. Two independent reviewers searched to identify randomized controlled trials comparing the effectiveness of SCS regimens to prevent relapse in children following treatment for acute asthma.

RESULTS

Fifteen studies were included. In 3 studies comparing SCS to placebo, asthma relapse was significantly reduced (RR = 0.10; 95% CI: 0.01, 0.77; I² = 0%). A network analysis identified a significant reduction in relapse in children treated with intramuscular corticosteroids (OR = 0.038; 95% CrI: 0.001, 0.397), short-course oral prednisone (OR = 0.054; 95% CrI: 0.002, 0.451), and oral dexamethasone (OR = 0.071; 95% CrI: 0.002, 0.733) compared to placebo.

CONCLUSION

This review found evidence that SCS reduces relapse in children following treatment for acute asthma, albeit based on a limited number of studies. Additional studies are required to assess the differential effect of SCS doses and treatment duration to prevent relapse in children following discharge for acute asthma.

Intramuscular versus oral corticosteroids to reduce relapses following discharge from the emergency department for acute asthma

BACKGROUND

Acute asthma is a common cause of presentations to acute care centres, such as the emergency department (ED), and while the majority of patients can be discharged, relapse requiring additional medical care is common. Systemic corticosteroids are a major part in the treatment of moderate to severe acute asthma; however, there is no clear evidence regarding the most effective route of administration for improving outcomes in patients discharged from acute care.

OBJECTIVES

To examine the effectiveness and safety of a single dose of intramuscular (IM) corticosteroids provided prior to discharge compared to a short course of oral corticosteroids in the treatment of acute asthma patients discharged from an ED or equivalent acute care setting.

SEARCH METHODS

The Cochrane Airways Group conducted searches of the Cochrane Airways Group Register of Trials, most recently on 14 March 2018. In addition in April 2017 we completed an extensive search of nine electronic databases including Medline, Embase, EBM ALL, Global Health, International Pharmaceutical Abstracts, CINAHL, SCOPUS, Proquest Dissertations and Theses Global, and LILACS. Furthermore, we searched the grey literature to identify any additional studies.

SELECTION CRITERIA

We included randomized controlled trials or controlled clinical trials if they compared the effectiveness of intramuscular (IM) versus oral corticosteroids to treat paediatric or adult patients presenting with acute asthma to an ED or equivalent acute care setting. Two independent reviewers assessed study eligibility and study quality. We resolved disagreements via a third party and assessed risk of bias using the Cochrane 'Risk of bias' tool. We assessed the quality of the evidence using GRADE.

DATA COLLECTION AND ANALYSIS

For dichotomous outcomes, we calculated individual and pooled statistics as risk ratios (RRs) with 95% confidence intervals (CIs) using a random-effects model. We reported continuous outcomes using mean difference (MD) or standardised mean difference (SMD) with 95% CIs using a random-effects model. We reported heterogeneity using I² and Cochran Q statistics. We used standard procedures recommended by Cochrane.

MAIN RESULTS

Nine studies involving 804 participants (IM = 402 participants; oral = 402 participants) met our review inclusion criteria. Four studies enrolled children (n = 245 participants), while five studies enrolled adults (n = 559 participants). All of the studies recruited participants presenting to an ED, except one study which recruited participants attending a primary care clinic. All of the paediatric studies compared intramuscular (IM) dexamethasone to oral prednisone/prednisolone. In the adult studies, the IM corticosteroid provided ranged from methylprednisolone, betamethasone, dexamethasone, or triamcinolone, while the regimen of oral corticosteroids provided consisted of prednisone, methylprednisolone, or dexamethasone. Only five studies were placebo controlled. For the purposes of this review, we did not take corticosteroid dose equivalency into account in the analysis. The most common co-intervention provided to participants during the acute care visit included short-acting beta₂-agonists (SABA), methylxanthines, and ipratropium bromide. In some instances, some studies reported providing some participants with supplemental oral or IV corticosteroids during their stay in the ED. Co-interventions provided to participants at discharge consisted primarily of SABA, methylxanthine, long-acting beta₂-agonists (LABA), and ipratropium bromide. The risk of bias of the included studies ranged from unclear to high across various domains. The primary outcome of interest was relapse to additional care defined as an unscheduled visit to a health practitioner for worsening asthma symptoms, or requiring subsequent treatment with corticosteroids which may have occurred at any time point after discharge from the ED.We found intramuscular and oral corticosteroids to be similarly effective in reducing the risk for relapse (RR 0.94, 95% CI 0.72 to 1.24; 9 studies, 804 participants; I² = 0%; low-quality evidence). We found no subgroup differences in relapse rates between paediatric and adult participants (P = 0.71), relapse occurring within or after 10 days post-discharge (P = 0.22), or participants with mild/moderate or severe exacerbations (P = 0.35). While we found no statistical difference between participants receiving IM versus oral corticosteroids regarding the risk for adverse events (RR 0.83, 95% CI 0.64 to 1.07; 5 studies, 404 participants; I² = 0%; moderate-quality evidence), an estimated 50 fewer patients per 1000 receiving IM corticosteroids reported experiencing adverse events (95% from 106 fewer to 21 more). We found inconsistent reporting of specific adverse events across the studies. There were no differences in the frequency of specific adverse events including nausea and vomiting, pain, swelling, redness, insomnia, or personality changes. We did not seek additional adverse events data.Participants receiving IM corticosteroids or oral corticosteroids both reported decreases in peak expiratory flow (MD -7.78 L/min, 95% CI -38.83 L/min to 23.28 L/min; 4 studies, 272 participants; I² = 33%; moderate-quality evidence), similar symptom persistence (RR 0.41, 95% CI 0.14 to 1.20; 3 studies, 80 participants; I² = 44%; low-quality evidence), and 24-hour beta-agonist use (RR 0.54, 95% CI 0.21 to 1.37; 2 studies, 48 participants; I² = 0%; low-quality evidence).

AUTHORS' CONCLUSIONS

There is insufficient evidence to identify whether IM corticosteroids are more effective in reducing relapse compared to oral corticosteroids among children or adults discharged from an ED or equivalent acute care setting for acute asthma. While we found no statistical differences, patients receiving IM corticosteroids reported fewer adverse events. Additional studies comparing the effectiveness of IM versus oral corticosteroids could provide further evidence clarity. Furthermore, there is a need for studies comparing different IM corticosteroids (e.g. IM dexamethasone versus IM methylprednisone) and different oral corticosteroids (e.g. oral dexamethasone versus oral prednisone), with consideration for dosing and pharmacokinetic properties, to better identify the optimal IM or oral corticosteroid regimens to improve patient outcomes. Other factors, such as patient preference and potential issues with adherence, may dictate practitioner prescribing.

Dexamethasone Compared to Prednisone for the Treatment of Children With Acute Asthma Exacerbations

Systemic corticosteroids are recommended in clinical practice guidelines for the treatment of acute asthma exacerbation based on evidence demonstrating reduced hospitalizations and improved outcomes after administration in the emergency department. Although prednisone and related oral preparations have been recommended previously, researchers have assessed dexamethasone as an alternative based on its longer biologic half-life and improved palatability. Systematic reviews of multiple small trials and 2 larger trials have found no difference in revisits to the emergency department compared to prednisone for dexamethasone given either as an intramuscular injection or orally. Studies of oral administration have found reduced emesis for dexamethasone compared to prednisone both in the emergency department and for a second oral dose, typically given 24 to 48 hours later. Studies assessing a single dose of dexamethasone have found equivalent improvement at follow-up but with some evidence of increased symptoms and increased need for additional corticosteroids compared to multiple doses of prednisone. Future research could further assess dexamethasone dose, formulation, and frequency and measure other related adverse effects such as behavior change. Consideration of baseline differences within the heterogeneous population of children requiring acute care for asthma may also guide the design of an optimal dexamethasone regimen.

Randomized Trial of Dexamethasone Versus Prednisone for Children with Acute Asthma Exacerbations

OBJECTIVE

To determine whether 2 doses of dexamethasone is as effective as 5 days of prednisolone/prednisone therapy in improving symptoms and quality of life of children with asthma exacerbations admitted to the emergency department (ED).

STUDY DESIGN

We conducted a randomized, noninferiority trial including patients aged 1-14 years who presented to the ED with acute asthma to compare the efficacy of 2 doses of dexamethasone (0.6 mg/kg/dose, experimental treatment) vs a 5-day course of prednisolone/prednisone (1.5 mg/kg/d, followed by 1 mg/kg/d on days 2-5, conventional treatment). Two follow-up telephone interviews were completed at 7 and 15 days. The primary outcome measures were the percentage of patients with asthma symptoms and quality of life at day 7. Secondary outcomes were unscheduled returns, admissions, adherence, and vomiting.

RESULTS

During the study period, 710 children who met the inclusion criteria were invited to participate and 590 agreed. Primary outcome data were available in 557 patients. At day 7, experimental and conventional groups did not show differences related to persistence of symptoms (56.6%, 95% CI 50.6-62.6 vs 58.3%, 95% CI 52.3-64.2, respectively), quality of life score (80.0 vs 77.7, not significant [ns]), admission rate (23.9% vs 21.7%, ns), unscheduled ED return visits (4.6% vs 3.3%, ns), and vomiting (2.1% vs 4.4%, ns). Adherence was greater in the dexamethasone group (99.3% vs 96.0%, P < .05).

CONCLUSION

Two doses of dexamethasone may be an effective alternative to a 5-day course of prednisone/prednisolone for asthma exacerbations, as measured by persistence of symptoms and quality of life at day 7.

CLINICAL TRIAL REGISTRATION

clinicaltrialsregister.eu: 2013-003145-42.

AT-RvD1 combined with DEX is highly effective in treating TNF-α-mediated disruption of the salivary gland epithelium

Sjögren's syndrome (SS) is an autoimmune disorder characterized by chronic inflammation and destruction of salivary and lacrimal glands leading to dry mouth and dry eyes, respectively. Currently, the etiology of SS is unknown and the current therapies have no permanent benefit; therefore, new approaches are necessary to effectively treat this condition. Resolvins are highly potent endogenous lipid mediators that are synthesized during the resolution of inflammation to restore tissue homeostasis. Previous studies indicate that the resolvin family member, RvD1, binds to the ALX/FPR2 receptor to block inflammatory signals caused by tumor necrosis factor-alpha (TNF-α) in the salivary epithelium. More recently, the corticosteroid, dexamethasone (DEX), was shown to be effective in reducing salivary gland inflammation. However, DEX, as with other corticosteroids, elicits adverse secondary effects that could be ameliorated when used in smaller doses. Therefore, we investigated whether the more stable aspirin-triggered (AT) epimer, AT-RvD1, combined with reduced doses of DEX is effective in treating TNF-α-mediated disruption of polarized rat parotid gland (Par-C10) epithelial cell clusters. Our results indicate that AT-RvD1 and DEX individually reduced TNF-α-mediated alteration in the salivary epithelium (i.e, maintained cell cluster formation, increased lumen size, reduced apoptosis, and preserved cell survival signaling responses) as compared to untreated cells. Furthermore, AT-RvD1 combined with a reduced dose of DEX produced stronger responses (i.e., robust salivary cell cluster formation, larger lumen sizes, further reduced apoptosis, and sustained survival signaling responses) as compared to those observed with individual treatments. These studies demonstrate that AT-RvD1 combined with DEX is highly effective in treating TNF-α-mediated disruption of salivary gland epithelium.

Pidotimod exacerbates allergic pulmonary infection in an OVA mouse model of asthma

Pidotimod is a synthetic dipeptide with biological and immuno‑modulatory properties. It has been widely used for treatment and prevention of recurrent respiratory infections. However, its impact on the regulation of allergic pulmonary inflammation is still not clear. In the current study, an ovalbumin (OVA)‑induced allergic asthma model was used to investigate the immune‑modulating effects of pidotimod on airway eosinophilia, mucus metaplasia and inflammatory factor expression compared with dexamethasone (positive control). The authors determined that treatment with pidotimod exacerbated pulmonary inflammation as demonstrated by significantly increased eosinophil infiltration, dramatically elevated immunoglobulin E production, and enhanced T helper 2 response. Moreover, treatment failed to attenuate mucus production in lung tissue, and did not reduce OVA‑induced high levels of FIZZ1 and Arg1 expression in asthmatic mice. In contrast, administration of dexamethasone was efficient in alleviating allergic airway inflammation in OVA‑induced asthmatic mice. These data indicated that pidotimod as an immunotherapeutic agent should be used cautiously and the effectiveness for controlling allergic asthma needs further evaluation and research.

Strategies parents use to give children oral medicine: a qualitative study of online discussion forums

AIM

The aim of this study was to describe strategies parents use to give oral medicine to children.

METHODS

We conducted an Internet-based qualitative study of posts from online forums where parents discussed how to give children oral medicine. The posts were analyzed using systematic text condensation. The investigators coded and developed groups iteratively, ending up with a consensus on final themes.

RESULTS

We included 4581 posts. Parents utilized three main strategies to give oral medicine to children: (1) Open administration give medicine to the child knowingly by changing the palatability, actively involve the child in play or use persuasion; (2) Hidden administration give medicine to the child unknowingly by camouflaging it in food, while sleeping or distracted by another activity; (3) Forced administration force children to take medicine with the use of restraint. Parents expressed three perspectives towards using force: Finding it unproblematic, using force despite not liking it or refusing to use force. No single strategy was described as the obvious first choice, and the strategies were not used in any particular order. Parents who gave up getting their child to ingest the medicine reported to contact the prescriber for a different medication, or stopped the treatment completely.

CONCLUSIONS

The three strategies are a robust and precise way to categorize techniques used by parents to give children oral medicine. We suggest that health professionals use the strategies to talk to parents and children about administration of oral medicines.

Is dexamethasone as effective as other corticosteroids for acute asthma exacerbation in children?

Dexamethasone has been proposed as an alternative in the treatment of acute asthma exacerbation in children. It allows shortening the duration of treatment, reducing costs and adverse effects. However, it is not clear whether its efficacy is similar to the traditional steroid regimen. To answer this question, we searched in Epistemonikos database, which is maintained by screening multiple information sources. We identified six systematic reviews including 10 randomized trials. We extracted data, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We concluded dexamethasone has probably fewer adverse effects than others corticosteroids, and might be equally effective in reducing hospitalizations and revisits.

Pediatric Respiratory Emergencies

Respiratory emergencies are 1 of the most common reasons parents seek evaluation for the their children in the emergency department (ED) each year, and respiratory failure is the most common cause of cardiopulmonary arrest in pediatric patients. Whereas many respiratory illnesses are mild and self-limiting, others are life threatening and require prompt diagnosis and management. Therefore, it is imperative that emergency clinicians be able to promptly recognize and manage these illnesses. This article reviews ED diagnosis and management of foreign body aspiration, asthma exacerbation, epiglottitis, bronchiolitis, community-acquired pneumonia, and pertussis.

A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department

STUDY OBJECTIVE

In acute exacerbations of asthma in children, corticosteroids reduce relapses, subsequent hospital admission, and the need for ß2-agonist bronchodilators. Prednisolone is the most commonly used corticosteroid, but prolonged treatment course, vomiting, and a bitter taste may reduce patient compliance. Dexamethasone has a longer half-life and has been used safely in other acute pediatric conditions. We examine whether a single dose of oral dexamethasone is noninferior to prednisolone in the emergency department (ED) treatment of asthma exacerbations in children, as measured by the Pediatric Respiratory Assessment Measure (PRAM) at day 4.

METHODS

We conducted a randomized, open-label, noninferiority trial comparing oral dexamethasone (single dose of 0.3 mg/kg) with prednisolone (1 mg/kg per day for 3 days) in patients aged 2 to 16 years and with a known diagnosis of asthma or at least 1 previous episode of ß2-agonist-responsive wheeze who presented to a tertiary pediatric ED. The primary outcome measure was the mean PRAM score (range of 0 to 12 points) performed on day 4. Secondary outcome measures included requirement for further steroids, vomiting of study medication, hospital admission, and unscheduled return visits to a health care practitioner within 14 days.

RESULTS

There were 245 enrollments involving 226 patients. There was no difference in mean PRAM scores at day 4 between the dexamethasone and prednisolone groups (0.91 versus 0.91; absolute difference 0.005; 95% CI -0.35 to 0.34). Fourteen patients vomited at least 1 dose of prednisolone compared with no patients in the dexamethasone group. Sixteen children (13.1%) in the dexamethasone group received further systemic steroids within 14 days after trial enrollment compared with 5 (4.2%) in the prednisolone group (absolute difference 8.9%; 95% CI 1.9% to 16.0%). There was no significant difference between the groups in hospital admission rates or the number of unscheduled return visits to a health care practitioner.

CONCLUSION

In children with acute exacerbations of asthma, a single dose of oral dexamethasone (0.3 mg/kg) is noninferior to a 3-day course of oral prednisolone (1 mg/kg per day) as measured by the mean PRAM score on day 4.

Pharmacotherapy of critical asthma syndrome: current and emerging therapies

The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.

The acute management of asthma

Patients presenting to the emergency department (ED) or clinic with acute exacerbation of asthma (AEA) can be very challenging varying in both severity and response to therapy. High-dose, frequent or continuous nebulized short-acting beta2 agonist (SABA) therapy that can be combined with a short-acting muscarinic antagonist (SAMA) is the backbone of treatment. When patients do not rapidly clinically respond to SABA/SAMA inhalation, the early use of oral or parenteral corticosteroids should be considered and has been shown to impact the immediate need for ICU admission or even the need for hospital admission. Adjunctive therapies such as the use of intravenous magnesium and helium/oxygen combination gas for inhalation and for driving a nebulizer to deliver a SABA and or SAMA should be considered and are best used early in the treatment plan if they are likely to impact the patients' clinical course. The use of other agents such as theophylline, leukotriene modifiers, inhaled corticosteroids, long-acting beta2 agonist, and long-acting muscarinic antagonist currently does not play a major role in the immediate treatment of AEA in the clinic or the ED but is an important therapeutic option for physicians to be aware of and to consider initiating at the time of discharge from clinic, hospital, or ED to reduce later clinical worsening and readmission to the ED and hospital. A comprehensive summary is provided of the currently available respiratory pharmaceuticals approved for asthma and other airway syndromes. Clinicians must be prepared to use the entire spectrum of medications available for the treatment of acute asthma exacerbations and the agents that should be initiated to prevent worsening or additional exacerbations. They need to be familiar with the major potential drug toxicities associated with their use.

Comparative Effectiveness of Dexamethasone versus Prednisone in Children Hospitalized with Asthma

OBJECTIVES

To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children hospitalized with asthma exacerbation not requiring intensive care.

STUDY DESIGN

This multicenter retrospective cohort study, using the Pediatric Health Information System, included children aged 4-17 years who were hospitalized with a principal diagnosis of asthma between January 1, 2007 and December 31, 2012. Children with chronic complex condition and/or initial intensive care unit (ICU) management were excluded. Propensity score matching was used to detect differences in length of stay (LOS), readmissions, ICU transfer, and cost between groups.

RESULTS

40,257 hospitalizations met inclusion criteria; 1166 (2.9%) received only dexamethasone. In the matched cohort (N = 1284 representing 34 hospitals), the LOS was significantly shorter in the dexamethasone group compared with the prednisone/prednisolone group. The proportion of subjects with a LOS of 3 days or more was 6.7% in the dexamethasone group and 12% in the prednisone/prednisolone group (P = .002). Differences in all-cause readmission at 7- and 30 days were not statistically significant. The dexamethasone group had lower costs of index admission ($2621 vs $2838; P < .001) and total episode of care (including readmissions) ($2624 vs $2856; P < .001) compared with the prednisone/prednisolone group. There were no clinical significant differences in ICU transfer or readmissions between groups.

CONCLUSIONS

Dexamethasone may be considered an alternative to prednisone/prednisolone for children hospitalized with asthma exacerbation not requiring admission to intensive care.

Is dexamethasone an effective alternative to oral prednisone in the treatment of pediatric asthma exacerbations?

BACKGROUND

A short course of systemic corticosteroids is an important therapy in the treatment of pediatric asthma exacerbations. Although a 5-day course of oral prednisone or prednisolone has become the most commonly used regimen, dexamethasone has also been used for a shorter duration (1-2 days) with potential for improvement in compliance and palatability. We reviewed the literature to determine if there is sufficient evidence that dexamethasone can be used as an effective alternative in the treatment of pediatric asthma exacerbations in the inpatient setting.

METHODS

A Medline search was conducted on the use of dexamethasone in the treatment of asthma exacerbations in children. The studies selected were clinical trials comparing the efficacy of dexamethasone with prednisone. Meta-analysis was performed examining physician revisitation rates and symptomatic return to baseline.

RESULTS

Six completed pediatric clinical trials met the inclusion criteria. All of the pediatric trials found that prednisone is not superior to dexamethasone in treating mild to moderate asthma exacerbations. Meta-analysis demonstrated homogeneity between the dexamethasone and prednisone groups when examining symptomatic return to baseline and unplanned physician revisits after the initial emergency department encounter. Some studies found potential additional benefits of dexamethasone, including improved compliance and less vomiting.

CONCLUSIONS

The current literature suggests that dexamethasone can be used as an effective alternative to prednisone in the treatment of mild to moderate acute asthma exacerbations in children, with the added benefits of improved compliance, palatability, and cost. However, more research is needed to examine the role of dexamethasone in hospitalized children.

Dexamethasone for acute asthma exacerbations in children: a meta-analysis

BACKGROUND AND OBJECTIVE

Dexamethasone has been proposed as an equivalent therapy to prednisone/prednisolone for acute asthma exacerbations in pediatric patients. Although multiple small trials exist, clear consensus data are lacking. This systematic review and meta-analysis aimed to determine whether intramuscular or oral dexamethasone is equivalent or superior to a 5-day course of oral prednisone or prednisolone. The primary outcome of interest was return visits or hospital readmissions.

METHODS

A search of PubMed (Medline) through October 19, 2013, by using the keywords dexamethasone or decadron and asthma or status asthmaticus identified potential studies. Six randomized controlled trials in the emergency department of children ≤18 years of age comparing dexamethasone with prednisone/prednisolone for the treatment of acute asthma exacerbations were included. Data were abstracted by 4 authors and verified by a second author. Two reviewers evaluated study quality independently and interrater agreement was assessed.

RESULTS

There was no difference in relative risk (RR) of relapse between the 2 groups at any time point (5 days RR 0.90, 95% confidence interval [CI] 0.46-1.78, Q = 1.86, df = 3, I2 = 0.0%, 10-14 days RR 1.14, 95% CI 0.77-1.67, Q = 0.84, df = 2, I2 = 0.0%, or 30 days RR 1.20, 95% CI 0.03-56.93). Patients who received dexamethasone were less likely to experience vomiting in either the emergency department (RR 0.29, 95% CI 0.12-0.69, Q = 3.78, df = 3, I2 = 20.7%) or at home (RR 0.32, 95% CI 0.14-0.74, Q = 2.09, df = 2, I2 = 4.2%).

CONCLUSIONS

Practitioners should consider single or 2-dose regimens of dexamethasone as a viable alternative to a 5-day course of prednisone/prednisolone.

Asthma update

Asthma continues to be one of the most common reasons for emergency department visits and a leading cause of hospitalization. Acute management involves severity-based treatment of bronchoconstriction and underlying airway inflammation. Optimal treatment has been defined and standardized through randomized controlled trials, systematic reviews, and consensus guidelines. Implementation of clinical practice guidelines may improve clinical, quality, and safety outcomes. Asthma morbidity is disproportionately high in poor, urban, and minority children. Children treated in emergency departments commonly have persistent chronic severity, significant morbidity, and infrequent follow-up and primary asthma care, and prescription of inhaled corticosteroids is appropriate.

Management of status asthmaticus in children

Recent literature on paediatric status asthmaticus (PSA) confirms an increasing percentage of admissions to paediatric intensive care units. PSA is a medical emergency that can be fatal and needs careful and prompt intervention. The severity of PSA is mainly determined by clinical judgement of signs and symptoms. Peak flow measurements and serial lung function measurements are not reliable in PSA. Validated clinically useful instruments are lacking. The three main factors that are involved in the pathophysiology of PSA, bronchoconstriction, mucus plugging and airway inflammation need to be addressed to optimise treatment. Initial therapies include supplementation of oxygen, repetitive administration of rapid acting β2-agonists, inhaled anticholinergics in combination with systemic glucocorticosteroids and intravenous magnesium sulphate. Additional treatment modalities may include methylxanthines, DNase, ketamine, sodium bicarbonate, heliox, epinephrine, non-invasive respiratory support, mechanical ventilation and inhalational anaesthetics.

Parental preference for short- versus long-course corticosteroid therapy in children with asthma presenting to the pediatric emergency department

Asthma is the most common chronic condition affecting children and a prominent chief complaint in pediatric emergency departments (ED). We aimed to determine parental preference between short- and long-term courses of oral corticosteroids for use in children with mild to moderate asthma presenting to our pediatric ED with acute asthma exacerbations. We surveyed parents of asthmatic children who presented to our pediatric ED from August 2011 to April 2012. Questions characterized each patient's asthma severity, assessed parental preference among systemic steroid and inhaled medication delivery options for acute asthma management, and inquired about compliance, medication costs, and intention to follow up. The majority of our parents prefer the use of 1 to 2 days of steroids to 5 days for acute asthma exacerbations in the ED. Thus, dexamethasone is an attractive alternative to prednisone/prednisolone and should be considered in the management of acute asthma exacerbations in the ED.

Therapeutic options for severe asthma

As the overall prevalence of asthma has escalated in the past decades, so has the population of patients with severe asthma. This condition is often difficult to manage due to the relative limitation of effective therapeutic options for the physician and the social and economic burden of the disease on the patient. Management should include an evaluation and elimination of modifiable risk factors such as smoking, allergen exposure, obesity and non-adherence, as well as therapy for co-morbidities like gastro-esophageal reflux disease and obstructive sleep apnea. Current treatment options include conventional agents such as inhalational corticosteroids, long acting β(2) agonists, leukotriene antagonists, and oral corticosteroids. Less conventional treatment options include immunotherapy with methotrexate, cyclosporine and tacrolimus, biological drugs like monoclonal antibodies, tumor necrosis factor-α blockers and oligonucleotides, phosphodiesterase inhibitors, antimicrobials and bronchial thermoplasty.

Single dose oral dexamethasone versus multi-dose prednisolone in the treatment of acute exacerbations of asthma in children who attend the emergency department: study protocol for a randomized controlled trial

Background

Asthma is a major cause of pediatric morbidity and mortality. In acute exacerbations of asthma, corticosteroids reduce relapses, subsequent hospital admission and the need for ß₂-agonist therapy. Prednisolone is relatively short-acting with a half-life of 12 to 36 hours, thereby requiring daily dosing. Prolonged treatment course, vomiting and a bitter taste may reduce patient compliance with prednisolone. Dexamethasone is a long-acting corticosteroid with a half-life of 36 to 72 hours. It is used frequently in children with croup and bacterial meningitis, and is well absorbed orally. The purpose of this trial is to examine whether a single dose of oral dexamethasone (0.3 mg/kg) is clinically non-inferior to prednisolone (1 mg/kg/day for three days) in the treatment of exacerbations of asthma in children who attend the Emergency Department.

Methods/design

This is a randomized, non-inferiority, open-label clinical trial. After informed consent with or without assent, patients will be randomized to either oral dexamethasone 0.3 mg/kg stat or prednisolone 1 mg/kg/day for three days. The primary outcome measure is the comparison between the Pediatric Respiratory Assessment Measure (PRAM) across both groups on Day 4. The PRAM score, a validated, responsive and reliable tool to determine asthma severity in children aged 2 to 16 years, will be performed by a clinician blinded to treatment allocation. Secondary outcomes include relapse, hospital admission and requirement for further steroid therapy. Data will be analyzed on an intention-to-treat and a per protocol basis. With a sample size of 232 subjects (105 in each group with an estimated 10% loss to follow-up), we will be able to reject the null hypothesis - that the population means of the experimental and control groups are equal with a probability (power) of 0.9. The Type I error probability associated with this test (of the null hypothesis) is 0.05.

Discussion

This clinical trial may provide evidence that a shorter steroid course using dexamethasone can be used in the treatment of acute pediatric asthma, thus eliminating the issue of compliance to treatment.

Registration

ISRCTN26944158 and EudraCT Number 2010-022001-18

Common pediatric respiratory emergencies

Pediatric respiratory illnesses are a huge burden to emergency departments worldwide. This article reviews the latest evidence in the epidemiology, assessment, management, and disposition of children presenting to the emergency department with asthma, croup, bronchiolitis, and pneumonia.

Asthma outcomes: exacerbations

BACKGROUND

The goals of asthma treatment include preventing recurrent exacerbations. Yet there is no consensus about the terminology for describing or defining "exacerbation" or about how to characterize an episode's severity.

OBJECTIVE

National Institutes of Health institutes and other federal agencies convened an expert group to propose how asthma exacerbation should be assessed as a standardized asthma outcome in future asthma clinical research studies.

METHODS

We used comprehensive literature reviews and expert opinion to compile a list of asthma exacerbation outcomes and classified them as either core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at a National Institutes of Health-organized workshop in March 2010 and finalized in September 2011.

RESULTS

No dominant definition of "exacerbation" was found. The most widely used definitions included 3 components, all related to treatment, rather than symptoms: (1) systemic use of corticosteroids, (2) asthma-specific emergency department visits or hospitalizations, and (3) use of short-acting β-agonists as quick-relief (sometimes referred to as "rescue" or "reliever") medications.

CONCLUSIONS

The working group participants propose that the definition of "asthma exacerbation" be "a worsening of asthma requiring the use of systemic corticosteroids to prevent a serious outcome." As core outcomes, they propose inclusion and separate reporting of several essential variables of an exacerbation. Furthermore, they propose the development of a standardized, component-based definition of "exacerbation" with clear thresholds of severity for each component.

Asthma in childhood

Management decisions for pediatric asthma (in patients younger than 12 years of age) based on extrapolation from available evidence in adolescents and adults (age 12 years and older) is common but rarely appropriate. This article addresses the disparity in response between the two age groups, presents the available pediatric evidence, and highlights the important areas in which further research is required. Evidence-based recommendations for acute and interval management of pediatric asthma are provided.

A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalised: a randomised controlled trial

OBJECTIVE

To determine whether a 5-day course of oral prednisolone is superior to a 3-day course in reducing the 2-week morbidity of children with asthma exacerbations who are not hospitalised.

DESIGN, SETTING AND PARTICIPANTS

Double-blind randomised controlled trial of asthma outcomes following a 5-day course of oral prednisolone (1 mg/kg) compared with a 3-day course of prednisolone plus placebo for 2 days. Participants were children aged 2-15 years who presented to the emergency departments of three Queensland hospitals between March 2004 and February 2007 with an acute exacerbation of asthma, but were not hospitalised. Sample size was defined a priori for a study power of 90%.

MAIN OUTCOME MEASURES

Difference in proportion of children who were symptom-free at Day 7, as measured by intention-to-treat (ITT) and per-protocol analysis; quality of life (QOL) on Days 7 and 14.

RESULTS

201 children were enrolled, and there was an 82% completion rate. There was no difference between groups in the proportion of children who were symptom-free (observed difference, 0.04 [95% CI, - 0.09 to 0.18] by ITT analysis; 0.04 [95% CI, - 0.17 to 0.09] by per-protocol analysis). There was also no difference between groups in QOL (P = 0.42). The difference between groups for the primary outcome was within the equivalence range calculated post priori.

CONCLUSION

A 5-day course of oral prednisolone confers no advantage over a 3-day course for children with asthma exacerbations who are not hospitalised.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN012605000305628.

A comparison of oral dexamethasone with oral prednisone in pediatric asthma exacerbations treated in the emergency department

The aim of this study was to determine if 2 doses of oral dexamethasone are as effective as a 5-day course of oral prednisone in preventing relapse for pediatric asthma exacerbations. Patients presenting to the emergency department with an asthma exacerbation were randomized to receive 0.6 mg/kg of dexamethasone or 2 mg/kg of prednisone in a prospective, double-blind study. The primary outcome was relapse within 10 days, and the secondary outcome was vomiting in the emergency department. Eighty-nine patients completed the study: 38 in the prednisone group and 51 in the dexamethasone group. In all, 3 patients in the prednisone group (8%) and 8 patients in the dexamethasone group (16%) required an unscheduled follow-up visit (P = .27). In all, 7 patients in the prednisone group (18%) and 5 patients in the dexamethasone group (10%) had vomiting ( P = .24). No difference was found in the relapse rate or incidence of vomiting between patients given prednisone and dexamethasone for pediatric asthma exacerbations.

[Management of acute asthma exacerbations in pediatrics]

Despite the significant advances that have been produced in the management of asthma in the last few decades, crises, attacks, or asthma exacerbations (acute asthma) continue to be the most common cause of consultation in pediatric emergency units. Visits to these units and hospital admissions due to acute asthma represent three quarters of the direct costs due to this disease. Acute asthma is a medical emergency that should be rapidly diagnosed and treated. Evaluation of children with acute asthma exacerbations should consist of two phases: a static phase (determination of the severity of the crisis on admission) and a dynamic phase (treatment response). The present article provides an in-depth review and analysis of current pharmacological and nonpharmacological treatments (oxygen, bronchodilators, corticosteroids - inhaled and systemic - aminophylline, magnesium sulfate, etc.) of acute asthma exacerbations and proposes management protocols for use in both primary care and emergency units.

Characterization of the antiallergic drugs 3-[2-(2-phenylethyl) benzoimidazole-4-yl]-3-hydroxypropanoic acid and ethyl 3-hydroxy-3-[2-(2-phenylethyl)benzoimidazol-4-yl]propanoate as full aryl hydrocarbon receptor agonists

The aryl hydrocarbon receptor (AhR) is a ligand-activated transcription factor that mediates most of the toxic effects of numerous chlorinated (e.g., TCDD) and nonchlorinated polycyclic aromatic compounds (e.g., benzo[ a]pyrene). Studies in AhR null mice suggested that this receptor may also play a role in the modulation of immune responses. Recently, two drugs, namely, M50354 and M50367 (ethyl ester derivative of M50354), were described as AhR ligands with high efficacy toward reducing atopic allergic symptoms in an AhR-dependent manner by skewing T helper cell differentiation toward a T H1 phenotype [Negishi et al. (2005) J. Immunol. 175 (11), 7348-7356]. Surprisingly, these drugs were shown to have minimal activity toward inducing classical dioxin responsive element-driven AhR-mediated CYP1A1 transcription. We synthesized and reevaluated the ability of these drugs to regulate AhR activity. In contrast to previously published data, both M50354 and M50367 were found to be potent inducers of several AhR target genes, namely, CYP1A1, CYP1B1, and UGT1A2. M50367 was a more effective agonist than M50354, perhaps accounting for its higher bioavailability in vivo. However, M50354 was capable of displacing an AhR-specific radioligand more effectively than M50367. This is consistent with M50354 being the active metabolite of M50367. In conclusion, two selective inhibitors of TH2 differentiation are full AhR agonists.

Asthma

Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.

Randomized trial of single-dose intramuscular dexamethasone compared with prednisolone for children with acute asthma

OBJECTIVES

To compare the clinical efficacy of single-dose intramuscular (IM) dexamethasone phosphate to a 5-day course of oral prednisolone for the treatment of moderate asthma exacerbations in young children discharged from the emergency department (ED).

METHODS

We performed a prospective, randomized trial in children aged 18 months to less than 7 years with asthma who presented to the ED with a clinical asthma score of 3 to 7 on a 9-point scale. Children were randomized to 1 dose of IM dexamethasone (0.6 mg/kg, maximum 15 mg) or oral prednisolone (2 mg/kg, maximum 50 mg) once daily for 5 days. The primary outcome, measured only for patients discharged from the ED, was change in asthma score from ED presentation to 4-day follow-up examination, as assessed by a physician masked to group assignment. We assessed secondary clinical course outcomes by a structured interview at 4 and 14 days.

RESULTS

Eighty-eight patients were appropriately randomized to dexamethasone and 93 to prednisolone. Group characteristics were similar at baseline. Among those discharged from the ED, 62 (90%) of 69 and 64 (90%) of 74 patients in the dexamethasone and prednisolone groups, respectively, were reassessed at 4 days for the primary outcome. The mean change in total asthma score at 4-day follow-up was 3.6 in the dexamethasone group and 3.4 in the prednisolone group (difference, 0.2; 95% confidence interval, -0.4 to 0.7). Of patients initially discharged, 5.9% of dexamethasone patients and 4.1% of prednisolone patients were admitted before the 2-week follow-up (difference, 1.8%; 95% confidence interval, -5.4% to 9.0%).

CONCLUSIONS

A single dose of IM dexamethasone showed no clinically meaningful difference in outcomes compared with a 5-day course of oral prednisolone for the treatment of moderate acute asthma exacerbations in young children who are discharged from the ED.

A model protocol for emergency medical services management of asthma exacerbations

Emergency medical services (EMS) is an important part of the continuum of asthma management. The magnitude of the EMS responsibility is very large, with millions of patients with asthma treated each year by EMS personnel. In response to inconsistencies between the 1997 National Asthma Education and Prevention Program asthma guidelines and a variety of existing EMS protocols on the management of asthma exacerbations, the Centers for Disease Control and Prevention convened a workgroup in 2004 to discuss the various opportunities and challenges ahead. At the meeting, and over the ensuing year, the workgroup created a model protocol that was derived from the National Asthma Education and Prevention Program guidelines. The model protocol is available in both text and algorithm format and offers guidance for EMS systems to develop and implement treatment protocols in their local areas. The workgroup recommendations emphasize flexibility, simplicity, and low-risk practices. By integrating these recommendations into existing protocols, we believe that EMS systems could improve prehospital care for patients with asthma. Demonstration projects are needed to carefully examine the implementation process and the actual impact of the model protocol on various outcomes. The workgroup also encourages more research on EMS management of asthma exacerbations. In the meantime, improved collaboration between EMS and national asthma organizations is an immediate priority and will continue to advance future discussions on how to improve asthma management in the prehospital setting. The workgroup hopes that state and local EMS systems will see the value of the model protocol and encourage its use.