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Three Part Question

In [patients with a mild to moderate acute asthma attack] is [one dose of intramuscular dexamethasone as efficacious as an oral course of prednisone] at [improving outcome]?

Clinical Scenario

A 4 year old girl with a known history of asthma presents in the emergency department with a two-day history of increased wheezing. She has been using her albuterol inhaler more frequently but is still symptomatic. Her symptoms improve after two nebulizer treatments, and as you prepare for her discharge you wonder if an IM dose of dexamethasone before discharge would be as effective as an oral course of prednisone at home.

Search Strategy

Medline 1950—2010 March Week 2 and EMBASE 1980—2010 Week 1 via the Ovid interface
((corticosteroid$ or steroid$).mp. OR exp Dexamethasone/ or dexamethasone.mp. or exp Methylprednisolone/ or methylprednisolone.mp. or exp Prednisone/ or prednisone.mp. or exp Prednisolone/ or prednisolone.mp.) AND (exp Injections, Intramuscular/ or intramuscular.mp. OR parenteral.mp. OR IM.mp.) AND (exp Asthma/ or asthma$.mp.) AND (exp Administration, Oral/ or oral.mp. OR PO.mp.) limit to All Child, 0–18 years.

Search Outcome

Embase 1980—2010 Week 1: 271 papers.

Medline 1950—2010 March Week 2: 47 papers

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Klig et al 1997, USA	44 children age 3 years to 16 years, with mild to moderate asthma exacerbation in the emergency department. IM Dexamethasone phosphate vs. oral prednisone for 3 days.	Prospective randomized trial, only investigators were blinded	Need for further medical attention	NSD	Symptoms reported by families, some patients were evaluated by health professionals, others were not. Patients and families not blinded, prednisone patients did not receive IM placebo dose, dexamethasone patients did not receive oral placebo
			Changes in symptoms at 5 days, reported by families	NSD
Gries et al, 2000, USA	32 children age 8 months to 7 years, with mild to moderate asthma exacerbation in pediatric clinic. IM Dexamethasone acetate approx 1.7 mg/kg/day vs. oral prednisone approx 2.2 mg/kg/day for 5 days	Prospective randomized trial, only investigators were blinded	Changes in symptoms at 4 days (clinical asthma score), reported by families	NSD (P =0 .98)	Clinic not ED setting. Asthma scores reported by families, no re-evaluation by medical personnel.Patients and families not blind, prednisone patients did not receive IM placebo dose, dexamethasone patients did not receive oral placebo Large proportion of prednisone patients did not receive full doses of medication
			Albuterol Use	NSD
			Need for further systemic steroids	NSD
			Tolerance of medications	Prednisone patients: 3/17 (18%) refused >75% of doses, 4/17 (24%) refused 30% of doses Dexamethasone patients: no doses missed
			Behavioral changes (e.g. personality changes)	NSD (71% in dexamethasone, 87% in prednisolone)
Gordon et al, 2007, USA	181 children age 18 months to 7 years, with moderate asthma exacerbation in emergency department. IM Dexamethasone phosphate 0.8 mg/kg/day vs. oral prednisolone 2 mg/kg/day for 5 days	Prospective randomized trial, only investigators were blinded	Changes in clinical asthma score on day 4, evaluated by attending and fellow physicians	NSD (78% versus 77%, p=0.52)	Patients and families not blinded, prednisone patients did not receive IM placebo dose, dexamethasone patients did not receive oral placebo. p-values not given for initial patient characteristics or for secondary outcomes (reported only confidence intervals). Compliance was recorded in the following manner: 94% of patients received at least 3 of the 5 doses of oral steroid. 3/5 doses is only 60% compliance.
			Hospital admission	NSD
			Changes in symptoms at 14 days, reported by families	NSD
			Need for unplanned medical visits	NSD

Comment(s)

Asthma is a common problem seen in the paediatric population presenting to the ED. Intramuscular dexamethasone is becoming a viable alternative to an oral course of corticosteroids, mainly because of difficulty in getting children to take oral steroids due to the bad taste of these preparations, and resulting poor compliance. A major consideration of the use of intramuscular dexamethasone in the ED setting is that of the half life of the medication: dexamethasone acetate has a half life of 2 weeks, whereas dexamethasone phosphate has a half life of 3 days.

Editor Comment

ED, Emergency Department; IM, intramuscular; NSD, no significant difference

Clinical Bottom Line

There are no significant clinical differences between a single dose of intramuscular dexamethasone and a 3–5 day course of oral prednisone or prednisolone.

References

1. Klig, JE, Hodge D 3rd, Rutherford MW. Symptomatic improvement following emergency department management of asthma: a pilot study of intramuscular dexamethasone versus oral prednisone. Journal of Asthma 1997; 34(5) 419-25.
2. Gries DM, Moffitt DR, Pulos E et al. A single dose of intramuscularly administered dexamethasone acetate is as effective as oral prednisone to treat asthma exacerbations in young children. Journal of Pediatrics 2000;136:298–303.
3. Gordon S, Tompkins T, Dayan P. Randomized trial of single-dose intramuscular dexamethasone compared with prednisolone for children with acute asthma. Pediatric Emergency Care 2007;23(8):521–527.