Dexamethasone Equivalent to Prednisone/Prednisolone in Symptomatic Improvement, Risk of Revisit for Acute Asthma Exacerbations
Clinical question: Are clinical outcomes for dexamethasone equivalent to currently recommended corticosteroids for the treatment of children with mild to moderate asthma exacerbations?
Background: National and international guidelines uniformly agree that administration of a systemic corticosteroid is appropriate for children hospitalized with mild to moderate asthma exacerbations. Based on available literature, a 2007 update to an expert panel report developed by the National Asthma Education and Prevention Program recommended prednisone, methylprednisolone, or prednisolone at 1-2 mg/kg daily in two divided doses (maximum 60 mg/day).
Recent small studies have begun to examine the use of dexamethasone in acute asthma exacerbations. The longer half-life of dexamethasone enables shorter treatment regimens, which can improve compliance. Additionally, its taste is considered superior compared to currently recommended corticosteroids.
Study designs: Two meta-analyses of randomized controlled trials (RCT).
Setting: Six RCTs published between 1997 and 2008.
Synopsis: Both groups searched Medline for RCTs using the search terms “dexamethasone” and “asthma”; additional search terms included “decadron” and “status asthmaticus.” Limiting the search to a pediatric population was achieved by either using appropriate medical subject heading terms or by using an age limiter of ≤18 years of age.
Both groups performed meta-analyses of clinical outcomes, including rates of revisit to a healthcare provider and symptomatic improvement. Adverse effects, specifically vomiting, also underwent meta-analysis by both groups.
Interestingly, both groups analyzed the same six studies, and all six studies were in the ED setting. The dexamethasone regimens in the analyzed studies included single-dose intramuscular (0.3-1.7 mg/kg), single-dose oral (0.6 mg/kg), or two-dose (0.6 mg/kg/day given once daily) oral regimens. These were compared to three- or five-day regimens of prednisone or prednisolone. Not surprisingly, both groups reached similar conclusions.
Regarding symptomatic improvement and revisit rates, there was no significant difference between dexamethasone and prednisone/prednisolone groups. Vomiting was less likely in the dexamethasone groups overall.
Bottom line: Meta-analyses of small RCTs examining dexamethasone in the treatment of acute asthma exacerbations show that it is equivalent to prednisone/prednisolone in symptomatic improvement and risk of revisit, and possibly superior with regard to the risk of vomiting.
Citations: Meyer JS, Riese J, Biondi E. Is dexamethasone an effective alternative to oral prednisone in the treatment of pediatric asthma exacerbations? Hosp Pediatr. 2014;4(3):172-180. Keeney GE, Gray MP, Morrison AK. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014;133(3):493-499.
Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.
