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Three Part Question

In [children with mild to moderate asthma exacerbation], does [oral single dose dexamethasone] [prevent relapses]?

Clinical Scenario

A 4-years-old boy with previous history of asthma presents to your Emergency Department with moderate asthma exacerbation. His condition improved with salbutamol and you are ready to discharge him. He already received one oral dose of dexamethasone. You wonder if there is enough evidence to discharge him without prescribing additional oral corticosteroid. You search the available literature.

Search Strategy

Search conducted on March 5th 2015
A. There were no completed BestBET, CATS or Cochrane review found on the topic.

B. The website clinicaltrials.gov was searched for an ongoing trial: one is currently recruiting patients over 18 years old (Single Oral Dose of Dexamethasone Versus Five Days of Prednisone in Adult Asthma).
C. MEDLINE (through PubMed)
1) ((asthma) OR (acute asthma exacerbation) OR (asthma[MeSH])) AND ((Glucocorticoids[Mesh]) OR (dexamethasone) OR (decadron)) = 4472
2) ((asthma) OR (acute asthma exacerbation) OR (asthma[MeSH])) AND ((Glucocorticoids[Mesh]) OR (dexamethasone) OR (decadron)) AND ((Pediatrics[Mesh]) OR (children)) = 1035
3) ((asthma) OR (acute asthma exacerbation) OR (asthma[MeSH])) AND ((Glucocorticoids[Mesh]) OR (dexamethasone) OR (decadron)) AND ((Pediatrics[Mesh]) OR (children)) AND (Emergency) = 84

Search Outcome

- Irrelevant articles were excluded → 4 articles remained
a. One meta-analysis was excluded because it included only one study evaluating po dexamethasone including results from Altamimi and colleagues
b. One meta analysis full text was not accessible
c. Cronin and colleagues published their methodology but no results are published yet.
d. Therefore 1 article remained

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Altamimi et al. 2006 Canada	2-16 years old Mild to moderate asthma exacerbation Randomization after second salbutamol treatment n=117	Single center Prospective Double blind Non inferiority 2 groups 1) Single dose of DEXAMETHASONE 0,6mg/kg max 18mg or 2) PREDNISONE 1mg/kg for 5 days	Pulmonary index score at discharge	no difference	ED co-treatment differs from standard care: same nebulized salbutamol dose for every patients No co-treatment with inhaled steroids at discharge (differs from standard care) No systematic follow-up after 5 days Limited relevance of vomiting evaluation since DEX and PRED were blended with a bittersweet syrup
			Unscheduled returns to the ED	DEX 4/56 PRED 1/54 no p value
			Patient self assessment sheet – return to baseline	no difference in number of days
			Vomiting	PRED : 2 subjects dropped out because of repeated vomiting DEX : no vomiting reported

Comment(s)

Altamimi and colleagues were the first to publish a study comparing a single dose of oral dexamethasone to a five-course day of prednisone. Their results suggest that the single dose regimen is similar to a five days regimen of prednisone. However, it is worth noticing that few patients were involved and co-interventions may be different in other EDs (no inhaled corticosteroids and salbutamol fixed dose). Nevertheless, this remains an interesting treatment alternative eliminating the issue of compliance.

Clinical Bottom Line

Single dose dexamethasone is an interesting alternative to a five days course of prednisone. Results of study conducted by Cronin and colleagues are pending. Their strong methodology will probably add to current scarce evidences with single dose oral dexamethasone in the treatment of mild to moderate bronchospasm in a pediatric population.

References

1. Altamimi, S., G. Robertson, W. Jastaniah, A. Davey, N. Dehghani, R. Chen, K. Leung and M. Colbourne (2006). Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma. Pediatr Emerg Care 2006 ; 786-793