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Glucocorticoids

Question 9:


In the child with an asthma exacerbation in the ED, should prednisolone/prednisone vs. dexamethasone be used to prevent hospitalization, to decrease time in the ED, and/or to improve pulmonary function?


Plain language summary from the office of evidence based practice:
Children with an asthma exacerbation present to the Emergency Department/Urgent Care Center (ED/UCC) with wheezing, tightness in their chest and difficulty breathing. Glucocorticosteroids (CS) are a first line medication used to reduce inflammation and reduce the symptoms of asthma. However, CS can have side effects, and reducing the side effects of a treatment is an important goal. The recommendation of the Asthma in the ED CPG (2012) team is to use prednisone/prednisolone over dexamethasone. It is based on the recommendation of The National Asthma Education and Prevention Program, Expert Panel Report: Guidelines for the Diagnoses and Management of Asthma (NAEP-EPR-3, 2007). The recommendations of various national and professional society guideline creators were compiled (See Table 1). There is no consensus across the guidelines on which CS to use for an asthma exacerbation.

There are two major types of CS that can be used. One is dexamethasone and the other is either prednisone (table) prednisolone (syrup). The medications are similar in how well and how quickly they decrease asthma symptoms. Prednisone and/or prednisolone have been the preferred medications to treat acute asthma because it is believed there are fewer side effects, such as hyperactivity, nausea, and reduced growth. Dexamethasone is a long acting steroid medication that is 5 times stronger than prednisone/prednisolone and has a longer half-life (Hendeles, 2003). A smaller, less frequent dose of the stronger medication may increase the ability of the child to take the medication. 

Therefore, the choice of using one CS over the other is based not on efficacy, but on outcomes that are not well studied, such as believed compliance to treatment and adverse events including (a) vomiting in the ED, (b) vomiting at home, and (c) adrenal suppression in children with frequent asthma exacerbations. Since the previous systematic review and abbreviated meta-analysis on this question, three studies (1 RCT and 3 meta-analyses) have been published (Cronin et al., 2015; Keeney et al., 2014; (Meyer, Riese, & Biondi, 2014); Normansell, Kew, & Mansour, 2016). They are added to this critically appraised topic.

Asthma team recommendation: Update Coming Soon!

Literature supporting this recommendation

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.