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Three Part Question

In [patients with acute severe asthma] are [oral prednisolone as good as intravenous hydrocortisone] in [improving respiratory symptoms]?

Clinical Scenario

A 24 year old male with asthma presents to the Emergency Department with severe wheeze and dyspnoea. While nebulised bronchodilators are being administered you wonder whether it is better to prescribe oral or intravenous steroids.

Search Strategy

Medline 1966-3/99 using the OVID interface.
{exp asthma OR asthma.mp} AND ([{exp steroids OR steroid$.mp OR exp prednisolone OR prednisolone.mp} AND {exp administration, oral OR oral.mp}] AND [{exp steroids OR steroid$.mp OR hydrocortisone.mp} AND {exp infusions,intravenous OR exp injections, intravenous OR intravenous.mp}]) LIMIT to human and english language.

Search Outcome

66 papers found of which 60 were irrelevant to the study question and one of insufficient quality for inclusion. All but one paper was included in a metaanlysis.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Rowe BH et al 1992 Canada	30 PRCTs of which * addressed the issue of oral vs intravenous therapy	Metaanalysis	Effectiveness in acute exacerbations	no significant difference
Barnett PL et al 1997 USA	49 children with moderate to severe asthma. 2 mg/kg oral methylprednisolone (23) vs 2 mg/kg intravenous prednisolone (26)	PRCT	Respiratory rate, FEV1, oxygen saturation	no significant difference	Follow up only 4 h. No power study
			Admission rate	no significant difference

Comment(s)

There is no good evidence for the superiority of either route of administration but all studies to date have been on very small numbers of patients. These studies may well have been of insufficient power to detect real differences (type II error).

Clinical Bottom Line

Steroids should continue to be given intravenously if intravenous access is necessary for other drugs or if the patient cannot take drugs by mouth. In other cases oral administration is acceptable.

References

1. Rowe BH, Keller JL, Oxman AD et al. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med 1992;10:301-310.
2. Barnett PL, Caputo GL, Baskin M et al. Intravenous versus oral corticosteroids in the management of acute asthma in children. Ann Emerg Med 1997;29:212-217.