General medicine/original research
Two Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A Randomized Controlled Trial

Presented at the Society for Academic Emergency Medicine annual meeting, 2005, New York, NY; and the Society for Academic Emergency Medicine regional meeting, April 2005, New York, NY.
https://doi.org/10.1016/j.annemergmed.2011.01.004Get rights and content

Study objective

Dexamethasone has a longer half-life than prednisone and is well tolerated orally. We compare the time needed to return to normal activity and the frequency of relapse after acute exacerbation in adults receiving either 5 days of prednisone or 2 days of dexamethasone.

Methods

We randomized adult emergency department patients (aged 18 to 45 years) with acute exacerbations of asthma (peak expiratory flow rate less than 80% of ideal) to receive either 50 mg of daily oral prednisone for 5 days or 16 mg of daily oral dexamethasone for 2 days. Outcomes were assessed by telephone follow-up.

Results

Ninety-six prednisone and 104 dexamethasone subjects completed the study regimen and follow-up. More patients in the dexamethasone group reported a return to normal activities within 3 days compared with the prednisone group (90% versus 80%; difference 10%; 95% confidence interval 0% to 20%; P=.049). Relapse was similar between groups (13% versus 11%; difference 2%; 95% confidence interval –7% to 11%, P=.67).

Conclusion

In acute exacerbations of asthma in adults, 2 days of oral dexamethasone is at least as effective as 5 days of oral prednisone in returning patients to their normal level of activity and preventing relapse.

Introduction

Asthma is the presenting complaint in almost 2 million emergency department (ED) visits annually and has been increasing in prevalence in the United States during the past 20 years.1 Systemic steroid administration (either oral or intravenous) has long been a cornerstone in the emergency treatment of acute asthma exacerbation, instrumental in both avoiding admission and shortening length of stay, as well as avoiding relapse.2, 3

Although much has been published on the equivalence of oral and intravenous steroid administration in these cases, little literature exists on the difference in effectiveness of various steroid preparations. Numerous policy statements recommend the use of systemic corticosteroids for patients with acute asthma exacerbations2, 4, 5 but do not compare different steroid preparations.

Many clinicians use a brief course of prednisone for mild to moderate asthma. Dexamethasone has an equivalent bioavailability in oral and intravenous formats but a longer half-life (up to 72 hours) than prednisone. As a result, it has been proffered as an alternative to prednisone that may allow shorter treatment regimens and improved compliance. In recent pediatric studies, shorter regimens of intramuscular or oral dexamethasone have demonstrated equivalence to prednisone and prednisolone in children with acute asthma.6, 7 These same studies also found improved patient compliance with the shorter dexamethasone regimen.

The objective of this study is to compare the time needed to return to normal activity and the frequency of relapse after acute exacerbation of asthma between patients receiving 2 days of oral dexamethasone versus 5 days of oral prednisone.

Section snippets

Study Design and Setting

This was a prospective, randomized, double-blind study conducted between 2004 and 2007 in the urban EDs at Albert Einstein Medical Center (census 75,000) and Temple University Hospital (census 70,000) in Philadelphia, PA. Both institutional review boards approved the study.

Selection of Participants

Patients aged 18 to 45 years, with a diagnosis of asthma for at least 6 months and a peak expiratory flow rate less than 80% predicted, were eligible for inclusion. Research assistants are present 24 hours a day, 7 days a

Results

Patient flow is shown in the Figure, and baseline characteristics were similar between study sites and between drug groups (Table 1).

Significantly more subjects returned to normal activity within 3 days with dexamethasone compared with prednisone, and the frequency of relapse was similar between groups (Table 2). The number of albuterol doses patients needed per day while receiving the study medication did not differ between the 2 groups (prednisone group: median 2 doses/day [interquartile

Limitations

We chose as a primary outcome to measure the number of days until patients believed they were able to return to their normal activities. Although some of the pediatric studies used calculated asthma scores as one of their outcome measures,8 patients in our study were followed up by telephone, making a more formal scoring system impossible to implement. However, we submit that a patient's return to normal baseline activity is the endpoint of a measured improvement in asthma score and can thus be

Discussion

Our results indicate that 2 days of oral dexamethasone is at least as effective as 5 days of prednisone in the treatment of mild to moderate asthma exacerbations in the ED. Relapse rates and treatment failures were equivalent in both groups. A statistically significant difference favoring the dexamethasone group was found in terms of returning patients to their normal activities within 3 days. This period was chosen according to the long 72-hour half-life of dexamethasone. Similar results have

References (12)

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Please see page 201 for the Editor's Capsule Summary of this article.

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Supervising editor: Steven M. Green, MD

Author contributions: JU and JF conceived of and designed the study. JK, PD, and PG collected the data. JK refined the protocol for acceptance, obtained institutional review board approval, obtained research funding, drafted the article, and functioned as the primary investigator in terms of data analysis and article preparation. PD served as the research coordinator, assisting in performing much of the statistical analysis. PG provided assistance with institutional review board forms and logistics in the implementation of the study. All authors contributed to the refinement and final preparations of the article. JK takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This study was made possible by an unrestricted grant from the Albert Einstein Society of the Albert Einstein Medical Center, grant number 03-14.

Publication date: Available online February 18, 2011.

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