Less Dexamethasone Matches More Prednisone for Acute Pediatric Asthma

Two doses of dexamethasone resulted in similar outcomes with better adherence than five days of prednisone in children with acute asthma.

Javier Benito, PhD, MD

Two doses of dexamethasone resulted in similar outcomes with better adherence than 5 days of prednisone or prednisolone in children treated in an emergency department (ED) for acute asthma exacerbation, according to a recent study.

The findings have clinical relevance and evidence lending to the idea that dexamethasone may serve as a valuable and efficient alternative to prednisone or prednisolone in managing nonlife-threatening asthma.

The traditional 5 days of prednisone/prednisolone is necessitated by a 12 to 36-hour half-life, while the 36 to 72-hour biological half-life of dexamethasone enables a 2-dose regimen.

Dexamethasone is also a more palatable option than prednisone/prednisolone, researchers noted, with the latter’s “bitter taste and incidence of vomiting (that) may lead to poor adherence, with an increased risk of persistent symptoms and hospitalization."

The study was led by Javier Benito, PhD, MD, and colleagues at the Pediatric Emergency Department and the Epidemiology Unit, Cruces University Hospital and BioCruces Health Research Institute, Bilbao, Basque Country, Spain.

The randomized, noninferiority trial was conducted with 590 children between the age of 1 and 14 years who presented to the ED between September 2014 and October 2015 with acute asthma exacerbation for which corticosteroid was indicated. Patients with mild exacerbations with no need of corticosteroid were excluded, as were those with severe presentations, or if corticosteroids had been used within the previous 4 weeks.

The corticosteroid was administered during the first hour of treatment, within an asthma exacerbation treatment protocol based on the pulmonary score (PS) and oxygen saturation (O2 sat) which included two to three inhalations of a ß2-agonist at 20-minute intervals, and subsequent doses or the addition of ipratropium bromide, and supplemental oxygen if required to maintain O2 sat at least at 93%.

Children were randomized to receive either dexamethasone 0.6 mg/kg (maximum 12 mg) followed by a second dose in 24 hours, or prednisone or prednisolone 1.5 mg/kg (maximum 60mg) twice daily for 5 days. The medications were provided in prepackaged doses to take home, so that compliance with filling the prescriptions was not a factor.

A lack of compliance with take-home corticosteroid prescriptions is not uncommon, said Amy Levine, MD, Professor of Pediatrics, Division of Pediatric Emergency Medicine, University of North Carolina, Chapel Hill. Citing a study that found less than half of children discharged from one ED had filld the prescription within 7 days, she commented in Emergency Physicians Monthly that the intended prescription "does not always go as planned".

Benito and colleagues conducted telephone follow-up interviews at 7 and 15 days after treatment to determine the primary study outcome of asthmatic status at 7 days, and such secondary outcomes as incidence of vomiting, adherence to treatment, parental satisfaction with child's status, ED readmission and hospitalization, visits to primary healthcare and school absenteeism.

The investigators found no statistically significant differences between the groups in any of the outcome measures, other than a greater adherence to the dexamethasone regimen (99.3% versus 96%, P<.05).

"Considering these findings, dexamethasone has replaced prednisone/prednisolone in the treatment of ED asthma exacerbations in our institution, without a negative impact in rates of hospitalization, ED revisits and ED revisits with admission," lead author Natalia Paniagua, PhD, MD, told MD Magazine.

The investigators did encounter, however, a high percentage (60%) of patients in both groups with persistent asthma symptoms at 7 days after ED consultation.

"This poor outcome of acute asthma episodes in children has been also documented by others, with high morbidity attributed to inadequate patients' follow-up in the outpatient setting or suboptimal use of controller medications for asthma,” researchers wrote.

The study, "Randomized Trial of Dexamethasone Versus Prednisone for Children with Acute Asthma Exacerbations," was published online in The Journal of Pediatrics in December.

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