When I said I would go into the top ten articles presented at the recent AAP NCE in San Diego I meant it. I plan to tackle each article and briefly review the results and try to drive home how this can impact your practice. First up, a steroid alternative for prednisone die-hards.
I’ve you’ve been a PEMBlog reader for a while you know that I’ve posted on the use of early steroids in asthma exacerbations – see the Why We Do What We Do post here. I also alluded to dexamethasone as a viable alternative to predsnisone/prednisolone. The following meta analysis from Keeney et al published in Pediatrics provides some evidence to that effect.
The bottom line
TWO days of Dexamethasone is equivalent to FIVE days of oral prednisone in the treatment of asthma exacerbations in the Pediatric Emergency Department
What they did
The authors queried PubMed and found six RCTs for dexamethasone in treating acute asthma exacerbations or status asthmaticus. They limited studies to those performed on patients ≤18 years of age. Ultimately they noted the following:
- No difference in risk of relapse between dexamethasone and predsnione at 5 days RR 0.90, 95% CI 0.46-1.78
- No difference in risk of relapse at 10-14 days RR 1.14, 95% CI 0.77-1.67
- No difference at risk of relapse at 30 days RR 1.20, 95% CI 0.03-56.93
- Dexamethasone patients were less likely to vomit in the ED RR 0.29, 95% CI 0.12-0.69
- Dexamethasone patients were less likely to vomit at home RR 0.32, 95% CI 0.14-0.74
What you can do
- Start using Dexamethasone (0.6mg/kg PO, IM or IV) in situations where you’d traditionally give prednisone in anticipation of a 5 day course
- After administering dose #1 in the ED as early as possible give the patient a prescription for oral Dexamethasone at home to be taken the following day as dose 2 of 2 for an asthma exacerbation
- Be aware that some of that reduction in vomiting is likely due to those patients that received IM dexamethasone
- Remember that many pharmacies may only carry the 1 mg/mL dilution of dexamethasone suspension, which means 5x the volume of prednisolone suspension (which is 5 mg/mL)
- Read the meta analysis for yourself!