Single Dex vs Multi Pred in Acute Exarcerbation of Asthma in ED

Welcome to the 14th JC of EUUHW. We’ve managed to discuss on another paediatric paper. This week attendance was surprisingly good.

Title : ›A Randomised Trial of Single-Dose Oral Dexamethasone vs Multidose Prednisolone for Acute Exarcerbations of Asthma in Children Who Attended the Emergency Department

Published : Annals of Emergency Medicine – May 2016

Objectives : To determine if single dose of oral dexamethasone was non inferior to prednisolone for 3 days in the treatment of acute exacerbation of asthma in children, as measured by Pediatric Respiratory Assessment Measure (PRAM) at day 4

Designs & Settings :

  • July 2011 – June 2012 ,
  • Single Center – ED in Dublin, tertiary paediatric hospital with annual attendances of 35,000
  • Open Label
  • Non inferiority study (Powered at 90% with sample size of 105 per arm)
  • Prerandomised pack of study envelopes (Random permuted block of 12)

Analysis : Intention to Treat

Population : 2-16 year old presented to ED with acute exacerbation of asthma with previous history of asthma (defined as either at least 1 previous episode of ß2-agonist -responsive wheeze or a previous diagnosis of asthma made by paediatrician or clinician of comparable experience.

Exclusion Criteria : ›

  • ›critical/life threatening
  • ›active varicella or HSV
  • ›concurrent RSV infection
  • ›temp > 39.5
  • ›use of oral or IV steroids in the previous 4 weeks
  • ›concurrent stridor
  • ›galactose intolerance
  • ›Lapp-lactase deficiency
  • ›glucose-galactose malabsorption
  • ›TB exposure
  • ›significant comorbid disease

Intervention : single dose oral dexamethasone 0.3mg/kg (max 12mg) – rounded to the nearest 2mg

Control : 3-day course of 1mg/kg/day od (max 40mg) – rounded to the nearest 5 mg

Screenshot 2016-05-04 08.51.01

Results : N = 235, Dexamethasone (n=120), Prednisolone (n=115)

Baseline characteristics : all not statistically significant except for gender – more male in prednisolone group (61.8% vs 74.6%, p=0.03)

Primary Outcome :

  • Mean PRAM Score at Day 4
    • Dexamethasone vs Prednisolone 0.91 (SD 1.16) vs 0.91 (SD 1.52)

Secondary Outcome : ›

  • ›PRAM Score change from ED to follow up
  • ›PRAM Score on discharge
  • ›ED length of stay
  • ›unscheduled visit within 14 days
  • ›readmission within 14 days
  • ›further steroids within 14 days
  • ›number of salbutamol therapies after enrollment

All not statistically significant except for further systemic steroids administered ›Dexamethasone vs Prednisolone : 13.1% vs 4.2% Difference 8.9% (1.9 to 16.0)

Discussion

What do we know about this topic so far?

  • BTS/Sign guideline recommend steroid treatment up to 3 days and consider IV steroids if unable to retain ingested medications

Screenshot 2016-05-04 08.31.27

  • Half life for prednisolone 12-36 hours
  • Half life for dexamethasone 36-72 hours
  • Dexamethasone has been safely used in croup and meningitis
  • 7 RCT involving different mode of delivery of dexamethasone vs prednisolone with most of the primary outcome looking at relapses
  • 1 Metaanalysis that suggest no difference in relative risk of relapse between dexamethasone and prednisolone group at any time. However those who receive dexamethasone were less likely to experience vomitting

Can we apply this?

  • At the moment, evidence shows there is no difference between single dose oral dexamethasone and 3-day doses of prednisolone in terms of asthma severity at Day 4/relapses
  • It is advisable if the child vomitted the prednisolone, he/she should be given dexamethasone as a replacement

What’s next?

  • At the moment, acute asthma management of the trust is being reviewed and there will be some changes in the near future
  • Kindly pay attention to the education board/notice board in the paediatric emergency unit (aminophylline might be back)

*Disclaimer : The opinions expressed by the finetuningem’s author/editor and those providing comments are theirs alone, and do not reflect the opinions of any professional organisation or group or any employee thereof

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