A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department

Cronin JJ, McCoy S, Kennedy U, An Fhailí SN, Wakai A, Hayden J, Crispino G, Barrett MJ, Walsh S, O'Sullivan R.

Annals of Emergency Medicine, 2016

Links   PubMed   Annals of Emergency Medicine   pdf

The Bottom Line

In this study, a single dose of Dexamethasone was non-inferior to a 3 day course of prednisone

What They Did

  • 226 afebrile children (they enrolled some twice for 245 total) age 2-16 with asthma were block randomized to get one dose of 0.3 mg/kg  Dexamethasone (max 12mg) or 3 days of Prednisone 1 mg/kg (max 40mg)
    • The only significant difference between the groups was a male predominance in the prednisone group
  • The prednisone arm did get drugs “to-go” when they left the ED – a research assistant oversaw dosing if a Prednisone patient got admitted
  • Patients were reassessed, in-person on day #4 – with PRAM score used for severity
  • Outcomes included:
    • Primary: mean PRAM score on day 4
    • Secondary: Requirement for further steroids, vomiting of study medication, hospital admission, and unscheduled return visits to a health care practitioner within 14 days
  • Overall they noted that:
    • There was no difference in mean PRAM at day 4 between Dex and Pred (0.91 versus 0.91; absolute difference 0.005; 95% CI –0.35 to 0.34)
    • 14 patients vomited at least 1 dose of red vs no Dex
    • 16 children (13.1%) in the dex group received further systemic steroids within 14 days vs 5 (4.2%) in the pred group (absolute difference 8.9%; 95% CI 1.9% to 16.0%)
    • There was no significant difference between the groups in hospital admission rates or the number of unscheduled return visits to a health care practitioner

What You Can Do

  • OK, so the obvious point is that these weren’t exactly what I’d consider “standard” doses. Typically I’ve given 0.6mg/kg Dexamethasone once a day for 2 days and 1 mg/kg prednisone once a day for 5 days
  • The allure of a single dose of Dexamethasone is enticing… But, given that we already know that 2 days of Dex equals 5 days of prednisone why not compare one day of Dex versus 2? Also, why max out at 40mg of predsnione? So many questions…
  • Know that the authors claim that “this is the first study comparing dexamethasone and prednisolone to use the PRAM score as the primary outcome measure.” But, it still isn’t in line with regular management – so I won’t be moving to single dose Dexamethasone at this point.
  • The higher proportion of children receiving more steroids in the Dex group is definitely worth further study