General medicine/original researchTwo Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A Randomized Controlled Trial
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
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Cited by (36)
Management of Asthma Exacerbations in the Emergency Department
2021, Journal of Allergy and Clinical Immunology: In PracticeCitation Excerpt :A systematic review of 6 RCTs showed no between-dose differences in FEV1, respiratory failure, or adverse effects,27 while daily doses of oral corticosteroids equivalent to 1 to 2 mg/kg prednisolone (for 3-5 days) in children and 50 mg prednisolone (for 5-7 days) in adults are considered sufficient for most asthma exacerbations.10 Recent research has also reported that a shorter duration of oral dexamethasone (eg, 0.6 mg/kg/d for 1-2 days in children; 12 mg/d for 1-2 days in adults) is tolerated, and just as effective as oral prednisolone in both children and adults.28-31 Although oral prednisone and intravenous methylprednisolone have an equivalent efficacy given the virtually complete bioavailability,32,33 oral corticosteroids are preferred under most circumstances.
Randomized Trial of Dexamethasone Versus Prednisone for Children with Acute Asthma Exacerbations
2017, Journal of PediatricsCitation Excerpt :A notable observation of the study was the high percentage of 60% of patients with persistent asthma symptoms 1 week after ED consultation. This poor outcome of acute asthma episodes in children has been also documented by others,33-35 with high morbidity attributed to inadequate patients' follow-up in the outpatient setting or suboptimal use of controller medications for asthma. At enrollment, approximately 40% of the patients presented with persistent asthma symptoms, which is consistent with data of previous studies.31,36,37
Care of Respiratory Conditions in an Observation Unit
2017, Emergency Medicine Clinics of North AmericaOne and Done: Steroids for Adult Asthma: Answers to the November 2016 Journal Club Questions
2017, Annals of Emergency MedicineCitation Excerpt :Subjectivity is often involved in forming the prior distribution because available data do not perfectly align with one's study question because of differences in medication dosing or study populations. For example, one may weigh data from the study by Kravitz et al8 more heavily because it is a study of adults, or one may weigh data from Keeney et al37 more heavily because more patients were studied. See the following references for further information on Bayesian analysis.4,34,36,41
A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma
2016, Annals of Emergency MedicineCitation Excerpt :Dexamethasone for acute asthma treatment emerged initially in the pediatric literature, with promising results.11-13 Kravitz et al14 evaluated a 2-dose regimen of oral dexamethasone in adults, demonstrating a statistically significant increase in return to normal activities in 3 days. Because there is a strong association between low adherence and poor outcomes,15,16 we posited that reducing the role of patient adherence to the care plan would improve outcomes.
Pediatric Respiratory Emergencies
2016, Emergency Medicine Clinics of North America
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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.