Oral Dexamethasone to Control Wheezing in Children at an Outpatient Clinic

Reducing oral steroid intolerability and drug costs for acute wheezers: A retrospective evaluation of a clinical management algorithm in a Pediatric Emergency Department

PROJECT AIM

To retrospectively evaluate a clinical management algorithm for acute wheezers in a UK Pediatric Emergency Department (PED).

OVERVIEW AND RATIONALE

Acute wheezing attacks are a leading cause of PED attendances and inpatient admissions. Prednisolone, a routine treatment, is intolerable in almost one-third of children, requiring repeated dosing, which may prolong length of stay (LOS). To address this problem, we: (1) developed an acute management algorithm (concise, single-sided flow-chart, instructing immediate management); (2) modified the OCS regime from prednisolone (1 mg/kg, 3-day course) to dexamethasone (600 then 300 mcg/kg); (3) and disseminated guidance regionally. Written information-handouts, e-mails, and posters-were followed-up with verbal reinforcement. We implemented the algorithm in 2017 and revised it further in 2018.

EVALUATION

In 2019, we retrospectively collected data on 100 acute wheeze attendances (those requiring OCS, aged 2-14), between October and December in 2016, 2017, and 2018 (n = 300), and assessed outcomes.

RESULTS

Over a 48-month period, we reduced OCS intolerability by 67.2% and OCS drug costs by 85.8% (saving £41,470.14), while not significantly influencing the other outcomes.

CONCLUSIONS

Reduced intolerability and substantial cost savings can be achieved by implementing a structured acute pediatric wheeze algorithm and modifying the OCS to single-dose dexamethasone (300 mcg/kg).

Quality improvement for paediatric asthma care in acute settings

PURPOSE OF REVIEW

This is a summative review of recent trends and novel programming integrated into various clinical settings (i.e. emergency departments, urgent care centres and paediatric clinics) to enhance the quality of care received by paediatric asthma patients Asthma is the most common chronic disease in paediatric patients and despite recognized national management guidelines, implementation and aftercare, especially in the emergency room, remain challenging.

RECENT FINDINGS

Outcome-based systematic quality improvement initiatives are described as well as evidence-based recommendations to enhance the education of providers, patients and caregivers.

SUMMARY

Many of the care initiatives described in the literature have been integrated into the emergency room. The authors feel some of these process improvements, such as pathway-based care, reducing time to delivery of medications, and personalized asthma education, may also be applicable and add value to clinical practice in additional community-based acute care settings such as urgent care centers and paediatric clinics.

Dexamethasone versus prednisone/prednisolone in the management of pediatric patients with acute asthmatic exacerbations: a systematic review and meta-analysis

OBJECTIVE

Acute asthmatic exacerbation is a common condition for pediatric emergency visits. Recently, dexamethasone has increasingly been used as an alternative to prednisone. This study aimed to evaluate the safety and efficacy of dexamethasone (DEX) against prednisone/prednisolone (PRED) in managing pediatric patients with acute asthmatic exacerbation.

DATA SOURCES

Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to August 2022 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42022353462).

STUDY SELECTIONS

From 316 studies screened, seventeen studies met the eligibility criteria, with 5967 pediatric patients experiencing an asthma exacerbation requiring treatment with either DEX (n = 2865) or PRED (n = 3102). Baseline patient characteristics (age, sex, PRAM (pediatric respiratory assessment measure), previous corticosteroid and beta-agonist inhaler) were comparable between groups.

RESULTS

After treatment administration, the DEX group had fewer vomiting incidents (OR = 0.24, 95% CI: 0.11, 0.51, I² = 58%) and reduced noncompliance events (OR = 0.12, 95% CI: 0.04, 0.34, I² = 0%) when compared to the PRED group. Regarding emergency-department (ED)-related outcomes, there were no differences in hospital admission rates (OR = 0.83, 95% CI: 0.58, 1.19, I² = 15%), time spent in the ED (MD= -0.11 h, 95% CI: -0.52; 0.30, I² = 82%) or relapse occurrences (OR = 0.67, 95% CI: 0.30, 1.49, I² = 52%) between both groups.

CONCLUSION

Although there were no differences between the DEX and PRED groups in terms of hospital admission rates, time spent in the ED or relapse events, pediatric patients receiving DEX experienced lower noncompliance and vomiting rates.

Corticosteroid choice and clinical outcomes for asthma exacerbations in the primary care setting

OBJECTIVE

To evaluate clinical outcomes in young children with acute asthma exacerbations treated with prednisone/prednisolone versus dexamethasone in the primary care setting.

METHODS

Retrospective cohort study of children ages 3-9 years with a primary care clinic visit for asthma and an associated oral corticosteroid (OCS) prescription fill in the Colorado All Payers Claim Database between 2/2013-3/2019. This was a secondary analysis of a dataset extracted to analyze risk of future development of asthma in younger children. The primary outcome was subsequent ED visit or hospital admission for asthma within 2-14 days after the index clinic visit. Demographics and asthma health services characteristics were assessed. Multivariable logistic regression was used to estimate the association between type of OCS prescription filled within 1 day of the index clinic visit and the primary outcome.

RESULTS

There were 3236 index clinic visits for asthma for 1918 children during the study period. Sixty-two percent were male and 66% were 3-4 years old. Prednisone/prednisolone accounted for 84% of OCS prescriptions fills within 1 day of the index clinic visit. One percent visited the ED and 1% required hospital admission within 2-14 days. In multivariate analysis, there was no statistical association between type of OCS prescribed and the primary outcome (OR 0.82; 95% CI: 0.37-1.8).

CONCLUSIONS

There are no differences in clinical outcomes by type of OCS prescribed for acute asthma exacerbations in the primary care setting. Due to better adherence and side effect profile, primary care providers may consider to use dexamethasone as the preferred OCS.

Primary care provider preferences for glucocorticoid management of acute asthma exacerbations in children

OBJECTIVE

Primary care providers (PCP) frequently care for children with acute asthma exacerbations in the outpatient setting. The objective of this study is to evaluate PCP preferences and perceptions regarding oral glucocorticoids prescribed from both outpatient primary care and ED settings for the treatment of children with acute asthma exacerbations.

METHODS

PCPs belonging to the Colorado Chapter of the American Academy of Pediatrics were surveyed between February and May 2019. Survey items were generated by a multidisciplinary team and underwent content and criteria validation and pilot testing. Survey items evaluated PCP preferred oral glucocorticoid and dosing regimen for children with acute asthma exacerbations, provider- and patient-level factors contributing to glucocorticoid preferences, and perception of glucocorticoid regimens in terms of treatment failure, resolution of symptoms and adherence.

RESULTS

A total of 109 of 600 (18.2%) PCPs responded. Equal proportions of PCPs reported preferring oral prednisone/prednisolone (50.5%) and oral dexamethasone (49.5%) for children with acute asthma exacerbations. Forty-four percent of PCPs reported no preference in type of glucocorticoid utilized by surrounding emergency departments (EDs). However, for children receiving dexamethasone in the ED but with persistent symptoms on PCP follow-up, 50.5% of PCPs would switch patients to prednisone/prednisolone. PCPs did not perceive more treatment failure or rapid resolution of symptoms with dexamethasone but reported better adherence with dexamethasone.

CONCLUSION

There is variability in PCP glucocorticoid management of pediatric acute asthma exacerbations. There is a need for further investigations to evaluate for differences in clinical outcomes based on PCP glucocorticoid treatment choices.