Reactive airway disease is a prevalent problem and, therefore, a common topic for the Morsels.  We have discussed my preference for MDIs over Nebs as well as the utility of Magnesium.  In addition, we have covered mechanical ventilation for asthma and how Delayed Sequence Intubation may be a useful tactic.  One aspect that we have not yet covered, though, is the utility of Dexamethasone for the treatment of Asthma.

Oral Steroids Are Useful

• Asthma is a chronic inflammatory disorder of the airways.
• Corticosteroids reduce airway hyperresponsiveness, inhibit inflammatory cell migration and activation, and block late-phase reaction to allergens. (Busse, 2007)
  • Inhaled Steroids improve control of asthma and are safe and well tolerated by children.
  • Inhaled Steroids do not improve acute exacerbations.
• Moderate or Severe Exacerbations require SYSTEMIC Steroids. (Busse, 2007)
  • High-dose inhaled corticosteroids are not effective in severe exacerbations. (Henedeles, 2003)
    • There is some evidence that children with good compliance to inhaled-corticosteroid regimens may be able to increase dose at onset of exacerbation to prevent need for systemic steroids. (Volovitz, 2008)
    • I’d say that these are generally not the patients presenting to your ED.
    • Use of inhaled-corticosteroids in the ED are generally aimed at improving technique, reinforcing eduction, and potential initiating their use.
  • Systemic steroids are recommended for patients not responding to initial short-acting Beta-agonists.

Taking Oral Steroids Can Be Challenging

Aside from the known side effects of steroids, convincing a child to take oral steroids can be difficult.

• Giving patients’ families prescriptions to get filled adds one more, potentially difficult, step to their management of the patient.
  • Some will have financial limitations.
  • Some will have transportation limitations.
  • Some will have “memory limitations” (Just forgot to get them).
• Even if the prednisone is obtained, the task of taking it is not easy.
  • Prednisone is generally not considered to be very tasty.
  • Short bursts of steroids are typically for 3-5 days, which doesn’t seem like that long of a time, until you are the parent trying “convince” him/her to take the medicine.

Dexamethasone May Offer a Better Option

• Dexamethasone Pharmacodynamics
  • Potency – Dexamethasone is 5-6 times more potent than prednisone.
  • Half-life – Dexamethasone has 4-5 longer 1/2 life than prednisone.
• Several small studies have investigated the utility of oral dexamethasone for acute asthma exacerbations.
  • Each has it’s own limitations (as so many studies do).
  • Meta-analyses have attempted to gather together the higher quality studies (and, naturally, have their own limitations).
• There does appear to be a consistent trend amongst these studies:
  • Oral Dexamethasone has similar efficacy, but has less side-effects (ex, vomiting) and improved compliance compared to prednisone. (Qureshi, 2001)
  • A SINGLE DOSE or TWO-DOSES of Oral Dexamethasone is NOT inferior to 5-day regimen of Prednisone. (Keeney, 2014) (Schwarz, 2014)
  • The use of oral dexamethasone is not associated with more unscheduled medical evaluations when compared to prednisone.
• Oral Dexamethasone is preferred by patients and families.
  • Families prefer the shorter duration of therapy (1 or 2 doses). (Williams, 2013)
  • Dexamethasone is more palatable compared to prednisone and is preferred by pediatric patients. (Hames, 2008)
• Decision analysis models have shown that 2 days of oral dexamethasone leads to cost savings (less return visits, admissions, etc) compared to 5 days of prednisone. (Lintzenich, 2012)

So the next time you are ordering oral steroids for your patients with acute asthma exacerbations, consider utilizing either a single dose or two-doses of dexamethasone as a way to improve compliance and lead to beneficial results.

References

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