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Inhaled Corticosteroid

Question 8:

In the child hospitalized with an asthma exacerbation, should inhaled steroids be initiated during an asthma exacerbation to improve pulmonary function or should inhaled corticosteroids be continued if the treatment is included on the child’s home Asthma Action Plan (AAP)?

Inpatient asthma team recommendation: 
We recommend starting or continuing an inhaled corticosteroid (ICS) in children hospitalized for an asthma exacerbation. We do not recommend treating an asthma exacerbation with inhaled corticosteroids ONLY. Doubling the AAP dose of ICS at the onset of an exacerbation is not recommended. However, starting or continuing ICS for an inpatient with an asthma exacerbation theoretically allows a foundation for assuring compliance with the AAP after discharge (Edmonds, Milan, Brenner, Camargo, & Rowe, 2012; EPR-3, 2007; Rowe, Edmonds, Spooner, Diner, & Camargo, 2004), although this has not been studied.

Literature supporting this recommendation: EPR-3 (2007) makes the following statements:

  • Doubling the dose of the ICS does not appear to be effective (FitzGerald et al., 2004); Garrett, Williams, Wong, & Holdaway, 1998; Harrison, Oborne, Newton, & Tattersfield, 2004). Multiple high doses of an ICS (6 mg flunisolide over 3 hours) may be helpful in adults.

  • In children, the data is inconsistent (Rowe et al., 2004) most likely due to inconsistency in study designs. A meta-analysis by (Edmonds et al., 2012)in a primarily adult population that compared ICS vs. oral steroid and ICS, there was no significant difference in the odds ratio (OR) for asthma relapse at 7-10 days post treatment OR = 0.72, 95% CI [0.48, 1.1] and hospital admission OR = 0.99, 95% CI [0.39, 2.52].

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.