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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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Kan-O K, Washio Y, Oki T, Fujimoto T, Ninomiya T, Yoshida M, Fujita M, Nakanishi Y, Matsumoto K. Effects of treatment with corticosteroids on human rhinovirus-induced asthma exacerbations in pediatric inpatients: a prospective observational study. BMC Pulm Med 2023; 23:487. [PMID: 38053068 DOI: 10.1186/s12890-023-02798-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 11/30/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Human rhinoviruses (HRVs) infection is a common cause of exacerbations in pediatric patients with asthma. However, the effects of corticosteroids on HRV-induced exacerbations in pediatric asthma are unknown. We conducted a prospective observational study to determine the viral pathogens in school-age pediatric inpatients with asthma exacerbations. We assessed the effects of maintenance inhaled corticosteroids (ICS) on the detection rates of HRV species and treatment periods of systemic corticosteroids during exacerbations on pulmonary lung function after exacerbations. METHODS Nasopharyngeal samples and clinical information were collected from 59 patients with asthma exacerbations between April 2018 and March 2020. Pulmonary function tests were carried out 3 months after exacerbations in 18 HRV-positive patients. Changes in forced expiratory volume in 1 second (FEV1)% predicted from baseline in a stable state were compared according to the treatment periods of systemic corticosteroids. RESULTS Fifty-four samples collected from hospitalized patients were analyzed, and viral pathogens were identified in 45 patients (83.3%) using multiplex PCR assay. HRV-A, -B, and -C were detected in 16 (29.6%), one (1.9%), and 16 (29.6%) patients, respectively. The detection rates of HRV-C were lower in the ICS-treated group compared with those in the ICS-untreated group (p = 0.01), whereas maintenance ICS treatment did not affect the detection rate for viral pathogens in total and HRV-A. Changes in FEV1% predicted in patients treated with systemic corticosteroids for 6-8 days (n = 10; median, 4.90%) were higher than those in patients treated for 3-5 days (n = 8; median, - 10.25%) (p = 0.0085). CONCLUSIONS Maintenance ICS reduced the detection rates of HRV (mainly HRV-C) in school-age inpatients with asthma exacerbations, and the treatment periods of systemic corticosteroids during exacerbations affected lung function after HRV-induced exacerbations. The protective effects of corticosteroids on virus-induced asthma exacerbations may be dependent upon the types of viral pathogen.
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Affiliation(s)
- Keiko Kan-O
- Department of Respiratory Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Yasuyoshi Washio
- Department of Respiratory Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takeshi Oki
- Division of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Tsuguto Fujimoto
- Department of Fungal Infection, National Institute of Infectious Diseases, Tokyo, Japan
| | - Takahito Ninomiya
- Division of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Makoto Yoshida
- Division of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Masaki Fujita
- Department of Respiratory Medicine, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Yoichi Nakanishi
- Department of Respiratory Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichiro Matsumoto
- Department of Respiratory Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Division of Respirology, Department of Medicine, Fukuoka Dental College, Fukuoka, Japan
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Omalizumab: An Optimal Choice for Patients with Severe Allergic Asthma. J Pers Med 2022; 12:jpm12020165. [PMID: 35207654 PMCID: PMC8878072 DOI: 10.3390/jpm12020165] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/28/2021] [Accepted: 12/30/2021] [Indexed: 11/25/2022] Open
Abstract
Omalizumab is the first monoclonal antibody that was globally approved as a personalized treatment option for patients with moderate-to-severe allergic asthma. This review summarizes the knowledge of almost two decades of use of omalizumab to answer some important everyday clinical practice questions, concerning its efficacy and safety and its association with other asthma-related and drug-related parameters. Evidence suggests that omalizumab improves asthma control and reduces the incidence and frequency of exacerbations in patients with severe allergic asthma. Omalizumab is also effective in those patients in reducing corticosteroid use and healthcare utilization, while it also seems to improve lung function. Several biomarkers have been recognized in predicting its efficacy in its target group of patients, while the optimal duration for evaluating its efficacy is between 16 and 32 weeks.
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Cai KJ, Su SQ, Wang YG, Zeng YM. Dexamethasone Versus Prednisone or Prednisolone for Acute Pediatric Asthma Exacerbations in the Emergency Department: A Meta-Analysis. Pediatr Emerg Care 2021; 37:e1139-e1144. [PMID: 32149991 DOI: 10.1097/pec.0000000000001926] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Yi-Ming Zeng
- Respiratory, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
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Leung JS. Paediatrics: how to manage acute asthma exacerbations. Drugs Context 2021; 10:dic-2020-12-7. [PMID: 34113386 PMCID: PMC8166724 DOI: 10.7573/dic.2020-12-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
Background Asthma is the most common chronic disease of childhood and a major source of childhood health burden worldwide. These burdens are particularly marked when children experience characteristic ‘symptom flare-ups’ or acute asthma exacerbations (AAEs). AAE are associated with significant health and economic impacts, including acute Emergency Department visits, occasional hospitalizations, and rarely, death. To treat children with AAE, several medications have been studied and used. Methods We conducted a narrative review of the literature with the primary objective of understanding the evidence of their efficacy. We present this efficacy evidence in the context of a general stepwise management pathway for paediatric AAEs. This framework is developed from the combined recommendations of eight established (inter)national paediatric guidelines. Discussion Management of paediatric AAE centres around four major care goals: (1) immediate and objective assessment of AAE severity; (2) prompt and effective medical interventions to decrease respiratory distress and improve oxygenation; (3) appropriate disposition of patient; and (4) safe discharge plans. Several medications are currently recommended with varying efficacies, including heliox, systemic corticosteroids, first-line bronchodilators (salbutamol/albuterol), adjunctive bronchodilators (ipratropium bromide, magnesium sulfate) and second-line bronchodilators (aminophylline, i.v. salbutamol, i.v. terbutaline, epinephrine, ketamine). Care of children with AAE is further enhanced using clinical severity scoring, pathway-driven care and after-event discharge planning. Conclusions AAEs in children are primarily managed by medications supported by a growing body of literature. Continued efforts to study the efficacy of second-line bronchodilators, integrate AAE management with long-term asthma control and provide fair/equitable care are required.
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Affiliation(s)
- James S Leung
- McMaster University, Faculty of Health Sciences, Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON, Canada
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Buddala PK, Chandrasekaran V, Harichandrakumar KT. A 3-day course of 1 mg/kg versus 2 mg/kg bodyweight prednisolone for 1- to 5-year-old children with acute moderate exacerbation of asthma: a randomized double-blind noninferiority trial. Paediatr Child Health 2020; 26:e189-e193. [PMID: 34136056 DOI: 10.1093/pch/pxaa082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background Even though the guidelines on the management of preschool asthma recommend early use of corticosteroids for acute moderate-to-severe exacerbations, considerable variation exists with regard to type and dose of steroids. Objectives To compare the clinical outcomes and side effect profile between 1 mg/kg/day and 2 mg/kg/day of oral prednisolone when administered for 3 days in preschool children with acute moderate asthma exacerbations. Study Design and Setting Randomized double-blind noninferiority trial was done in the paediatric emergency of a teaching hospital. Patients Interventions and Outcomes A total of 128 children aged 1 to 5 years who presented to the paediatric emergency with acute moderate exacerbation of asthma were enrolled. They were randomized into two groups. One group received 1 mg/kg/day and the other 2 mg/kg/day of oral prednisolone for 3 days. Severity of asthma exacerbation was measured by Pediatric Respiratory Assessment Measure (PRAM) score. The PRAM scores, wheeze recurrence, and side effect profile were compared and analyzed between the two groups. Results The difference in the PRAM scores at 1, 2, 3, and 4 hours after intervention between the two groups was statistically insignificant. Need for escalation of therapy, salbutamol nebulization, time for resolution of symptoms, and recurrence of wheeze were similar between the two groups. Vomiting was significantly less frequent in low-dose group with a relative risk of 0.19 to 0.99 compared to high-dose prednisolone. Conclusion Prednisolone at a dose of 1 mg/kg/day was not inferior to 2 mg/kg/day in terms of clinical improvement and recurrence of wheeze within 1 week and has less frequent vomiting compared to higher dose.
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Affiliation(s)
- Pavan Kumar Buddala
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Venkatesh Chandrasekaran
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - K T Harichandrakumar
- Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Rodriguez-Martinez CE, Sossa-Briceño MP, Castro-Rodriguez JA. Dexamethasone or prednisolone for asthma exacerbations in children: A cost-effectiveness analysis. Pediatr Pulmonol 2020; 55:1617-1623. [PMID: 32394644 DOI: 10.1002/ppul.24817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/02/2020] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Jose A Castro-Rodriguez
- Department of Pediatric Pulmonology, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
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Fernandes RM, Wingert A, Vandermeer B, Featherstone R, Ali S, Plint AC, Stang AS, Rowe BH, Johnson DW, Allain D, Klassen TP, Hartling L. Safety of corticosteroids in young children with acute respiratory conditions: a systematic review and meta-analysis. BMJ Open 2019; 9:e028511. [PMID: 31375615 PMCID: PMC6688746 DOI: 10.1136/bmjopen-2018-028511] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 06/24/2019] [Accepted: 07/03/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Ricardo M Fernandes
- Pediatrics, Hospital de Santa Maria, Lisbon, Portugal
- Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Laboratory of Clinical Pharmacology and Therapeutics, Lisbon, Portugal
| | - Aireen Wingert
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Samina Ali
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Women & Children's Health Research Institute, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Amy C Plint
- Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Antonia S Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brian H Rowe
- Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - David W Johnson
- Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dominic Allain
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Terry P Klassen
- Manitoba Institute of Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Kirkland SW, Vandermeer B, Campbell S, Villa-Roel C, Newton A, Ducharme FM, Rowe BH. Evaluating the effectiveness of systemic corticosteroids to mitigate relapse in children assessed and treated for acute asthma: A network meta-analysis. J Asthma 2018; 56:522-533. [PMID: 29693459 DOI: 10.1080/02770903.2018.1467444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Scott W Kirkland
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada
| | - Ben Vandermeer
- b Department of Pediatrics, Alberta Research Centre for Health Evidence , University of Alberta, Edmonton Clinic Health Academy , Edmonton , AB , Canada
| | - Sandy Campbell
- c J.W. Scott Health Sciences Library , University of Alberta , Walter C. Mackenzie Health Sciences Centre, Edmonton , AB , Canada
| | - Cristina Villa-Roel
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada
| | - Amanda Newton
- d Department of Pediatrics , University of Alberta , Edmonton , AB , Canada
| | - Francine M Ducharme
- e Departments of Pediatrics and of Social and Preventive Medicine , University of Montreal , Montreal , Quebec , Canada
| | - Brian H Rowe
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada.,f School of Public Health, University of Alberta , Edmonton Clinic Health Academy , Edmonton , AB , Canada
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Kitazawa H, Yamaide A, Wada T, Arakawa H. CQ8 Are systemic corticosteroids for prevention of relapse following acute exacerbations of bronchial asthma in children effective? ACTA ACUST UNITED AC 2017. [DOI: 10.3388/jspaci.31.343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hiroshi Kitazawa
- Department of general Pediatrics, Division of Allergy, Miyagi Children’s Hospital
| | - Akiko Yamaide
- Department of Allergy and Rheumatology, Chiba Children’s Hospital
| | - Takuya Wada
- Department of Pediatrics, University of Toyama
| | - Hirokazu Arakawa
- Department of Pediatrics, Gunma University Graduate School of Medicine
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Abstract
BACKGROUND Asthma is a common long-term breathing condition that affects approximately 300 million people worldwide. People with asthma may experience short-term worsening of their asthma symptoms; these episodes are often known as 'exacerbations', 'flare-ups', 'attacks' or 'acute asthma'. Oral steroids, which have a potent anti-inflammatory effect, are recommended for all but the most mild asthma exacerbations; they should be initiated promptly. The most often prescribed oral steroids are prednisolone and dexamethasone, but current guidelines on dosing vary between countries, and often among different guideline producers within the same country. Despite their proven efficacy, use of steroids needs to be balanced against their potential to cause important adverse events. Evidence is somewhat limited regarding optimal dosing of oral steroids for asthma exacerbations to maximise recovery while minimising potential side effects, which is the topic of this review. OBJECTIVES To assess the efficacy and safety of any dose or duration of oral steroids versus any other dose or duration of oral steroids for adults and children with an asthma exacerbation. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov (www.ClinicalTrials.gov), the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/) and reference lists of all primary studies and review articles. This search was up to date as of April 2016. SELECTION CRITERIA We included parallel randomised controlled trials (RCTs), irrespective of blinding or duration, that evaluated one dose or duration of oral steroid versus any other dose or duration, for management of asthma exacerbations. We included studies involving both adults and children with asthma of any severity, in which investigators analysed adults and children separately. We allowed any other co-intervention in the management of an asthma exacerbation, provided it was not part of the randomised treatment. We included studies reported as full text, those published as abstract only and unpublished data. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results for included trials, extracted numerical data and assessed risk of bias; all data were cross-checked for accuracy. We resolved disagreements by discussion with the third review author or with an external advisor.We analysed dichotomous data as odds ratios (ORs) or risk differences (RDs) using study participants as the unit of analysis; we analysed continuous data as mean differences (MDs). We used a random-effects model, and we carried out a fixed-effect analysis if we detected statistical heterogeneity. We rated all outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system and presented results in 'Summary of findings' tables. MAIN RESULTS We included 18 studies that randomised a total of 2438 participants - both adults and children - and performed comparisons of interest. Included studies assessed higher versus lower doses of prednisolone (n = 4); longer versus shorter courses of prednisolone (n = 3) or dexamethasone (n = 1); tapered versus non-tapered courses of prednisolone (n = 4); and prednisolone versus dexamethasone (n = 6). Follow-up duration ranged from seven days to six months. The smallest study randomised just 15 participants, and the largest 638 (median 93). The varied interventions and outcomes reported limited the number of meaningful meta-analyses that we could perform.For two of our primary outcomes - hospital admission and serious adverse events - events were too infrequent to permit conclusions about the superiority of one treatment over the other, or their equivalence. Researchers in the included studies reported asthma symptoms in different ways and rarely used validated scales, again limiting our conclusions. Secondary outcome meta-analysis was similarly hampered by heterogeneity among interventions and outcome measures used. Overall, we found no convincing evidence of differences in outcomes between a higher dose or longer course and a lower dose or shorter course of prednisolone or dexamethasone, or between prednisolone and dexamethasone.Included studies were generally of reasonable methodological quality. Review authors assessed most outcomes in the review as having low or very low quality, meaning we are not confident in the effect estimates. The predominant reason for downgrading was imprecision, but indirectness and risk of bias also reduced our confidence in some estimates. AUTHORS' CONCLUSIONS Evidence is not strong enough to reveal whether shorter or lower-dose regimens are generally less effective than longer or higher-dose regimens, or indeed that the latter are associated with more adverse events. Any changes recommended for current practice should be supported by data from larger, well-designed trials. Varied study design and outcome measures limited the number of meta-analyses that we could perform. Greater emphasis on palatability and on whether some regimens might be easier to adhere to than others could better inform clinical decisions for individual patients.
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Affiliation(s)
- Rebecca Normansell
- St George's, University of LondonPopulation Health Research InstituteLondonUKSW17 0RE
| | - Kayleigh M Kew
- St George's, University of LondonPopulation Health Research InstituteLondonUKSW17 0RE
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Aljebab F, Choonara I, Conroy S. Systematic review of the toxicity of short-course oral corticosteroids in children. Arch Dis Child 2016; 101:365-70. [PMID: 26768830 PMCID: PMC4819633 DOI: 10.1136/archdischild-2015-309522] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 12/02/2015] [Accepted: 12/03/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Short-course oral corticosteroids are commonly used in children but are known to be associated with adverse drug reactions (ADRs). This review aimed to identify the most common and serious ADRs and to determine their relative risk levels. METHODS A literature search of EMBASE, MEDLINE, International Pharmaceutical Abstracts, CINAHL, Cochrane Library and PubMed was performed with no language restrictions to identify studies in which oral corticosteroids were administered to patients aged 28 days to 18 years of age for up to and including 14 days of treatment. Each database was searched from their earliest dates to December 2013. All studies providing clear information on ADRs were included. RESULTS Thirty-eight studies including 22 randomised controlled trials (RCTs) met the inclusion criteria. The studies involved a total of 3200 children in whom 850 ADRs were reported. The three most frequent ADRs were vomiting, behavioural changes and sleep disturbance, with respective incidence rates of 5.4%, 4.7% and 4.3% of patients assessed for these ADRs. Infection was one of the most serious ADRs; one child died after contracting varicella zoster. When measured, 144 of 369 patients showed increased blood pressure; 21 of 75 patients showed weight gain; and biochemical hypothalamic-pituitary-adrenal axis suppression was detected in 43 of 53 patients. CONCLUSIONS Vomiting, behavioural changes and sleep disturbance were the most frequent ADRs seen when short-course oral corticosteroids were given to children. Increased susceptibility to infection was the most serious ADR. TRIAL REGISTRATION NUMBER CRD42014008774. By PROSPERO International prospective register of systematic reviews.
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Affiliation(s)
- Fahad Aljebab
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
| | - Imti Choonara
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
| | - Sharon Conroy
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
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Cronin JJ, McCoy S, Kennedy U, An Fhailí SN, Wakai A, Hayden J, Crispino G, Barrett MJ, Walsh S, O'Sullivan R. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med 2015; 67:593-601.e3. [PMID: 26460983 DOI: 10.1016/j.annemergmed.2015.08.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 06/18/2015] [Accepted: 07/31/2015] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- John J Cronin
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Siobhan McCoy
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Una Kennedy
- Department of Emergency Medicine, St James's Hospital, Dublin 8, Ireland
| | - Sinéad Nic An Fhailí
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland
| | - Abel Wakai
- Emergency Care Research Unit, Division of Population Health Sciences, Royal College of Surgeons, Dublin 2, Ireland
| | - John Hayden
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland
| | | | - Michael J Barrett
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland; Department of Paediatrics, University College Dublin, Belfield, Dublin 4, Ireland
| | - Sean Walsh
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Ronan O'Sullivan
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland; Department of Paediatrics, University College Dublin, Belfield, Dublin 4, Ireland; School of Medicine, University College Cork, Cork, Ireland.
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Petsky HL, Li AM, Au CT, Kynaston JA, Turner C, Chang AB. Management based on exhaled nitric oxide levels adjusted for atopy reduces asthma exacerbations in children: A dual centre randomized controlled trial. Pediatr Pulmonol 2015; 50:535-43. [PMID: 24891337 DOI: 10.1002/ppul.23064] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 04/04/2014] [Indexed: 11/08/2022]
Abstract
While several randomized control trials (RCTs) have evaluated the use of fractional exhaled nitric oxide (FeNO) to improve asthma outcomes, none used FeNO cut-offs adjusted for atopy, a determinant of FeNO levels. In a dual center RCT, we assessed whether a treatment strategy based on FeNO levels, adjusted for atopy, reduces asthma exacerbations compared with the symptoms-based management (controls). Children with asthma from hospital clinics of two hospitals were randomly allocated to receive an a-priori determined treatment hierarchy based on symptoms or FeNO levels. There was a 2-week run-in period and they were then reviewed 10 times over 12-months. The primary outcome was the number of children with exacerbations over 12-months. Sixty-three children were randomized (FeNO = 31, controls = 32); 55 (86%) completed the study. Although we did achieve our planned sample size, significantly fewer children in the FeNO group (6 of 27) had an asthma exacerbation compared to controls (15 of 28), P = 0.021; number to treat for benefit = 4 (95% CI 3-24). There was no difference between groups for any secondary outcomes (quality of life, symptoms, FEV1 ). The final daily inhaled corticosteroids (ICS) dose was significantly (P = 0.037) higher in the FeNO group (median 400 µg, IQR 250-600) compared to the controls (200, IQR100-400). Taking atopy into account when using FeNO to tailor asthma medications is likely beneficial in reducing the number of children with severe exacerbations at the expense of increased ICS use. However, the strategy is unlikely beneficial for improving asthma control. A larger study is required to confirm or refute our findings.
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Affiliation(s)
- Helen L Petsky
- Queensland Children's Medical Research Institute, Queensland University of Technology, Herston, Australia
| | - Albert M Li
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Chun T Au
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jennifer A Kynaston
- General Paediatrician, Royal Children's Hospital, Herston, Brisbane, Queensland, Australia
| | - Catherine Turner
- School of Nursing & Midwifery, The University of Queensland, Brisbane, Queensland, Australia
| | - Anne B Chang
- Queensland Children's Medical Research Institute, Queensland University of Technology, Herston, Australia.,Child Health Division, Menzies School of Health, Darwin, Northern Territory, Australia
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Keeney GE, Gray MP, Morrison AK, Levas MN, Kessler EA, Hill GD, Gorelick MH, Jackson JL. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics 2014; 133:493-9. [PMID: 24515516 PMCID: PMC3934336 DOI: 10.1542/peds.2013-2273] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Jeffrey L. Jackson
- General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and,Zablocki VAMC, Milwaukee, Wisconsin
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16
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Rhinoviruses. VIRAL INFECTIONS OF HUMANS 2014. [PMCID: PMC7120790 DOI: 10.1007/978-1-4899-7448-8_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Petrisko MA, Skoner JD, Skoner DP. Safety and efficacy of inhaled corticosteroids (ICS) in children with asthma. J Asthma 2013; 45 Suppl 1:1-9. [PMID: 19093279 DOI: 10.1080/02770900802631361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Inhaled corticosteroids (ICS) are the guideline-preferred preventative therapy for persistent asthma of all severity levels and for all ages, including children. While these drugs are unquestionably efficacious, concerns of adverse systemic effects limit patient compliance with treatment regimens and thus the attainable benefits. Suppression of bone growth, bone density, and HPA axis function, in addition to cataract formation and elevated intraocular pressure/glaucoma, have been associated with ICS use. This review will focus on recent developments in the safety and efficacy of ICS as compared to oral CS corticosteroids and the achievement of a balance between risk and benefit in optimizing ICS therapy.
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Abstract
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.
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Affiliation(s)
- Kyle A Nelson
- Emergency Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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Cronin J, Kennedy U, McCoy S, An Fhailí SN, Crispino-O'Connell G, Hayden J, Wakai A, Walsh S, O'Sullivan R. 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. Trials 2012; 13:141. [PMID: 22909281 PMCID: PMC3492215 DOI: 10.1186/1745-6215-13-141] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 07/17/2012] [Indexed: 11/10/2022] Open
Abstract
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
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Affiliation(s)
- John Cronin
- Paediatric Emergency Research Unit, Emergency Department, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
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Ranjan R. Drug treatment of acute severe asthma in children. World J Pediatr 2012; 8:88-9; author reply 89-90. [PMID: 22282389 DOI: 10.1007/s12519-012-0341-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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de Vries M, Berendsen AJ, Bosveld HEP, Kerstjens HAM, van der Molen T. COPD exacerbations in general practice: variability in oral prednisolone courses. BMC FAMILY PRACTICE 2012; 13:3. [PMID: 22239907 PMCID: PMC3323421 DOI: 10.1186/1471-2296-13-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 01/12/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND The use of oral corticosteroids as treatment of COPD exacerbations in primary care is well established and evidence-based. However, the most appropriate dosage regimen has not been determined and remains controversial. Corticosteroid therapy is associated with a number of undesirable side effects, including hyperglycaemias, so differences in prescribing might be relevant. This study examines the differences between GPs in dosage and duration of prednisolone treatment in patients with a COPD exacerbation. It also investigates the number of general practitioners (GPs) who adjust their treatment according to the presence of diabetic co-morbidity. METHODS Cross-sectional study among 219 GPs and 25 GPs in training, located in the Northern part of the Netherlands. RESULTS The response rate was 69%. Nearly every GP prescribed a continuous dose of prednisolone 30 mg per day. Among GPs there were substantial differences in treatment duration. GPs prescribed courses of five, seven, ten, or fourteen days. A course of seven days was most common. The duration of treatment depended on exacerbation and disease severity. A course of five days was especially prescribed in case of a less severe exacerbation. In a more severe exacerbation duration of seven to fourteen days was more common. Hardly any GP adjusted treatment to the presence of diabetic co-morbidity. CONCLUSION Under normal conditions GPs prescribe prednisolone quite uniformly, within the range of the current Dutch guidelines. There is insufficient guidance regarding how to adjust corticosteroid treatment to exacerbation severity, disease severity and the presence of diabetic co-morbidity. Under these circumstances, there is a substantial variation in treatment duration.
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Affiliation(s)
- Marianne de Vries
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, FA 20, 9700 AD Groningen, the Netherlands
| | - Annette J Berendsen
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, FA 20, 9700 AD Groningen, the Netherlands
| | - Henk EP Bosveld
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, FA 20, 9700 AD Groningen, the Netherlands
| | - Huib AM Kerstjens
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Thys van der Molen
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, FA 20, 9700 AD Groningen, the Netherlands
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Chang AB, Robertson CF, van Asperen PP, Glasgow NJ, Masters IB, Mellis CM, Landau LI, Teoh L, Morris PS. Can a management pathway for chronic cough in children improve clinical outcomes: protocol for a multicentre evaluation. Trials 2010; 11:103. [PMID: 21054884 PMCID: PMC2989328 DOI: 10.1186/1745-6215-11-103] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 11/06/2010] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Chronic cough is common and is associated with significant economic and human costs. While cough can be a problematic symptom without serious consequences, it could also reflect a serious underlying illness. Evidence shows that the management of chronic cough in children needs to be improved. Our study tests the hypothesis that the management of chronic cough in children with an evidence-based management pathway is feasible and reliable, and improves clinical outcomes. METHODS/DESIGN We are conducting a multicentre randomised controlled trial based in respiratory clinics in 5 major Australian cities. Children (n = 250) fulfilling inclusion criteria (new patients with chronic cough) are randomised (allocation concealed) to the standardised clinical management pathway (specialist starts clinical pathway within 2 weeks) or usual care (existing care until review by specialist at 6 weeks). Cough diary, cough-specific quality of life (QOL) and generic QOL are collected at baseline and at 6, 10, 14, 26, and 52 weeks. Children are followed-up for 6 months after diagnosis and cough resolution (with at least monthly contact from study nurses). A random sample from each site will be independently examined to determine adherence to the pathway. Primary outcomes are group differences in QOL and proportion of children that are cough free at week 6. DISCUSSION The clinical management pathway is based on data from Cochrane Reviews combined with collective clinical experience (250 doctor years). This study will provide additional evidence on the optimal management of chronic cough in children. TRIAL REGISTRATION ACTRN12607000526471.
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Affiliation(s)
- AB Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Queensland Children's Respiratory Centre and Queensland Children's Medical Research Institute, Royal Children's Hospital, Brisbane, Qld, Australia
| | - CF Robertson
- Department of Respiratory Medicine, Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - PP van Asperen
- Department of Respiratory Medicine, The Children's Hospital at Westmead, University of Sydney, NSW, Australia
| | - NJ Glasgow
- Medicine School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - IB Masters
- Queensland Children's Respiratory Centre and Queensland Children's Medical Research Institute, Royal Children's Hospital, Brisbane, Qld, Australia
| | - CM Mellis
- Central Clinical School, University of Sydney, NSW, Australia
| | - LI Landau
- Postgraduate Medical Council of Western Australia, Health Department of Western Australia, Perth, Australia
| | - L Teoh
- The Canberra Hospital, Australian Capital Territory, Australia
| | - PS Morris
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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Kelly HW. What Is the Dose of Systemic Corticosteroids for Severe Asthma Exacerbations in Children? ACTA ACUST UNITED AC 2009. [DOI: 10.1089/pai.2009.2202.ph] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
PURPOSE OF REVIEW Asthma continues to be a major chronic disease in children, and acute asthma exacerbations are common. Although the basic therapy of asthma exacerbations has not changed, recent studies have demonstrated improved outcomes with different modes of delivery of medications, improved patients' self-management of their asthma, and recognition of risk factors for severe exacerbations. RECENT FINDINGS Recent studies in children have shown that written action plans based on symptom recognition are more effective than action plans based on peak expiratory flows. Bronchodilator administration by metered-dose inhaler is becoming the preferred therapy for treating mild-to-moderate asthma exacerbations in the emergency department, but nebulizers may still have a role in home and inpatient asthma management. High-dose inhaled corticosteroids may be as effective as oral corticosteroids for acute asthma exacerbations. A novel treatment strategy has titrated combination therapy with budesonide and formoterol for both maintenance and relief of symptoms. Lastly, the contributions of obesity and genetic variation to severe asthma exacerbations are becoming known, and noninvasive positive pressure ventilation has become an option for patients in severe asthma exacerbations. SUMMARY Improvements in management strategies can significantly improve outcomes in children with asthma.
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Abstract
BACKGROUND : Viral respiratory illness triggers asthma exacerbations, but the influence of respiratory illness on the acute severity and recovery of childhood asthma is unknown. Our objective was to evaluate the impact of a concurrent acute respiratory illness (based on a clinical definition and PCR detection of a panel of respiratory viruses, Mycoplasma pneumoniae and Chlamydia pneumoniae) on the severity and resolution of symptoms in children with a nonhospitalized exacerbation of asthma. METHODS : Subjects were children aged 2 to 15 years presenting to an emergency department for an acute asthma exacerbation and not hospitalized. Acute respiratory illness (ARI) was clinically defined. Nasopharyngeal aspirates (NPA) were examined for respiratory viruses, Chlamydia and Mycoplasma using PCR. The primary outcome was quality of life (QOL) on presentation, day 7 and day 14. Secondary outcomes were acute asthma severity score, asthma diary, and cough diary scores on days 5, 7, 10, and 14. RESULTS : On multivariate regression, presence of ARI was statistically but not clinically significantly associated with QOL score on presentation (B = -0.36, P = 0.025). By day 7 and 14, there was no difference between groups. Asthma diary score was significantly higher in children with ARI (B = 0.41, P = 0.039) on day 5 but not on presentation or subsequent days. Respiratory viruses were detected in 54% of the 78 NPAs obtained. There was no difference in the any of the asthma outcomes of children grouped by positive or negative NPA. CONCLUSIONS : The presence of a viral respiratory illness has a modest influence on asthma severity, and does not influence recovery from a nonhospitalized asthma exacerbation.
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Petsky HL, Acworth JP, Clark R, Thearle DM, Masters IB, Chang AB. Asthma and protracted bronchitis: who fares better during an acute respiratory infection? J Paediatr Child Health 2009; 45:42-7. [PMID: 19208065 DOI: 10.1111/j.1440-1754.2008.01433.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM Acute respiratory infections (ARI) are common in children, and symptoms range from days to weeks. The aim of this study was to determine if children with asthma have more severe ARI episodes compared with children with protracted bronchitis and controls. METHODS Parents prospectively scored their child's next ARI using the Canadian acute respiratory illness and flu scale (CARIFS) and a validated cough diary (on days 1-7, 10 and 14 of illness). Children were age- and season-matched. RESULTS On days 10 and 14 of illness, children with protracted bronchitis had significantly higher median CARIFS when compared with children with asthma and healthy controls. On day 14, the median CARIFS were: asthma = 4.1 (interquartile range (IQR) 4.0), protracted bronchitis = 19.6 (IQR 25.8) and controls = 4.1 (IQR 5.25). The median cough score was significantly different between groups on days 1, 7, 10 and 14 (P < 0.001). A significantly higher proportion of children with protracted bronchitis (63%) were still coughing at day 14 in comparison with children with asthma (24%) and healthy controls (26%). CONCLUSION Children with protracted bronchitis had the most severe ARI symptoms and higher percentage of respiratory morbidity at day 14 in comparison with children with asthma and healthy controls.
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Affiliation(s)
- Helen L Petsky
- Department of Respiratory Medicine, Royal Children's Hospital, Queensland, Australia.
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