Clinical

Prednisone, dexamethasone likely equivalent for hospitalized kids with asthma


 

REPORTING FROM PHM 2019

Two doses of oral dexamethasone given 24 hours apart seemed as effective for inpatient pediatric asthma as a 5-day course of prednisone, based on a review of 284 children admitted for asthma exacerbations at Children’s Hospital and Medical Center in Omaha, Neb.

M. Alexander Otto/MDedge News

Dr. Aleisha Nabower

The finding speaks to an ongoing question in pediatric hospital medicine: Can dexamethasone can be used instead of prednisone for asthma? Reviews on the outpatient and ED sides have found that dexamethasone – which has a longer half-life than prednisone – is at least as effective. Compliance is likely better with the two-dose regimen, there seems to be less vomiting, and it’s less expensive, explained lead investigator Aleisha Nabower, MD, an assistant professor of pediatrics at the University of Nebraska, Omaha.

However, evidence is lacking on the inpatient side, where children are sicker. Some hospitalists opt for prednisone since it’s been used more widely and has a more robust evidence base. Others, however, are shifting to dexamethasone because of the easier dosing and reassuring outpatient findings, she said at Pediatric Hospital Medicine.

Dr. Nabower and associates wanted to bring more certainty to the issue, so they compared outcomes in 195 children admitted for asthma exacerbations treated with prednisone/prednisolone (pred) at 2 mg/kg once, then 1 mg/kg twice a day for 4 days; 35 children treated with two 0.6 mg/kg doses dexamethasone (dex) 24 hours apart; and 54 treated with dexamethasone then prednisolone (dex/pred) at 0.6 mg/kg dexamethasone in the ED, then 1 mg/kg prednisolone twice a day for 4 days.

In short, “we really didn’t see a difference, so perhaps you could use dexamethasone,” Dr. Nabower said at the meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

There were no statistically significant baseline differences. The mean age was about 6 years, there were more boys than girls in each group, and over half the children had mild persistent asthma. Most of the rest had moderately persistent asthma.

The mean Clinical Respiratory Score of about 4.3 points on admission fell to about 0.5 at 32 hours, around the mean length of stay, in all three groups.

The only statistically significant difference in escalation of care was that 80% of dex/pred children, versus about 50% in the other groups, were put on ipratropium. It wasn’t caused by differences in respiratory scores, but rather by greater overall use of the agent at about the same time that the hospital started requiring one dose of dexamethasone in the ED, whether children were switched on the floor or not, the investigators noted.

Differences in continuous albuterol use – 22% of pred, 35% of dex, and 43% of dex/pred children – were nonsignificant, as was magnesium sulfate use: 6% pred, 9% dex, and 13% dex/pred. Less than 5% of children in all three groups were put on antibiotics.

There was one 7-day readmission in both the pred and dex groups. One child in the dex group was transferred to the pediatric ICU. The differences were again nonsignificant.

Dr. Nabower was careful to note that the results are just a suggestion of equivalency. A randomized trial is needed to rule out differences definitively.

Direct pediatric ICU admissions and children on corticosteroids in the previous month were excluded from the investigation. As expected, children started on intravenous methylprednisolone in the ED had greater escalation of care and longer hospital stays.

There was no external funding for the work, and Dr. Nabower didn’t report any disclosures.

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