Oral Steroids for Children With Asthma Exacerbations
Abstract & Commentary
Source: Schuh S, et al. Comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma. N Engl J Med 2000;343:689-694.
This randomized, placebo-controlled trial examined children at least 5 years of age presenting to the emergency department (ED) with acute, moderate-to-severe asthma exacerbations (FEV1 < 60% predicted). Otherwise healthy children not taking oral steroids or high-dose inhaled steroids were treated with nebulized albuterol and ipratropium bromide. Twenty minutes after the first respiratory treatment, the children received either oral prednisone syrup 2 mg/kg or inhaled fluticasone 2 mg (8 inhaler puffs in a single dose via spacer).
One hundred children participated in the study. Baseline characteristics of the two treatment groups were comparable. Over four hours, FEV1 improvement was significantly greater in the prednisone group than in the fluticasone group (18.9% vs 9.4%). No children in the prednisone group had a decline in FEV1, whereas 25% of the fluticasone group showed spirometric deterioration. Hospitalization rates were significantly lower in the prednisone group than in the fluticasone group (10% vs 31%). Less than one-half of the children returned at eight days for scheduled follow-up. The prednisone group appeared to have sustained its FEV1 improvement; however, the authors do not report whether this difference was significant. The authors conclude that children with acute asthma who require steroid therapy should receive oral rather than inhaled medication.
Comment by David J. Karras, MD, FAAEM, FACEP
Five years ago, Scarfone and colleagues published an influential article comparing oral prednisone to inhaled dexamethasone in children at least 1 year of age with moderate asthma exacerbations.1 The authors found hospitalization rates were comparable between the two groups, with significantly earlier discharges and a lower relapse rate in the dexamethasone group. They concluded that inhaled dexamethasone is at least as effective as oral prednisone in children with asthma.
Dexamethasone, however, is far from an ideal inhaled corticosteroid. Unlike steroids designed for inhalation, dexamethasone absorbed through the lungs (or swallowed) is active systemically. It appears that these systemic effects are responsible for the drug’s efficacy in treating asthma, yet these effects also mitigate any advantage dexamethasone may have over oral steroid therapy. Fluticasone, on the other hand, has no significant systemic activity and is not absorbed via the GI tract.
The present study examined older children who were able to cooperate with spirometric testing, which is a far better measure of drug efficacy than hospitalization rates. For these reasons, I find this study a bit more compelling than the study by Scarfone and colleagues. If systemic steroid therapy is chosen for acute asthma management in children, prednisone remains the drug of choice. Inhalation therapy requires choosing between dexamethasone—which is highly absorbed and systemically active—and steroids truly designed for inhalation, which unfortunately appear relatively ineffective in treating acute disease.
References
1. Scarfone RJ, et al. Nebulized dexamethasone versus oral prednisone in the emergency treatment of asthmatic children. Ann Emerg Med 1995;26:480-486.
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