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Dexamethasone versus prednisolone in asthma

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 19502010 March Week 2 and EMBASE 19802010 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, 018 years.

Search Outcome

Embase 19802010 Week 1: 271 papers.

Medline 19502010 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 blindedNeed for further medical attentionNSDSymptoms 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 familiesNSD
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 daysProspective randomized trial, only investigators were blindedChanges in symptoms at 4 days (clinical asthma score), reported by familiesNSD (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 UseNSD
Need for further systemic steroidsNSD
Tolerance of medicationsPrednisone 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 daysProspective randomized trial, only investigators were blindedChanges in clinical asthma score on day 4, evaluated by attending and fellow physiciansNSD (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 admissionNSD
Changes in symptoms at 14 days, reported by familiesNSD
Need for unplanned medical visitsNSD

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 35 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;136:298303.
  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):521527.