Single-Dose IM Dexamethasone Alone Effective for Acute Asthma

November 03, 2003

Alicia Ault

Nov. 3, 2003 (New Orleans) — Children with prior episodes of asthma who present to emergency rooms can be treated effectively with a single dose of intramuscular (IM) dexamethasone, potentially replacing a five-day course of oral steroids, researchers reported here Friday at the annual meeting of the American Academy of Pediatrics.

Stephen L. Gordon, MD, from the Children's Hospital of New York–Presbyterian, presented data from a prospective randomized study comparing a single dose of IM dexamethasone (0.6 mg/kg up to a maximum of 15 mg) to five days of oral prednisolone (2 mg/kg/day). Ages of the children in the study ranged from 18 months to 6 years, and they had at least two documented previous episodes of moderate to severe asthma.

A total of 1,713 children were evaluated, but 1,158 were excluded for scoring too low on the Asthma Score scale, which assigns points for respiratory rate, wheezing, and rate of retractions. To be eligible for study, children were required to score between 3 and 7 out of a total 9 points.

After further exclusions and withdrawals, 88 patients were assigned to dexamethasone and 93 to prednisolone. The primary endpoint was the Asthma Score at four-day follow-up. Mean initial score was 4.51 in the dexamethasone-treated patients and 4.27 in the prednisolone-treated patients. For both groups, both mean four-day score and mean decline in score were similar, with most patients dropping to a score of 1 or less.

About 27% of the dexamethasone group and 21% of the prednisolone group had a score above 1 at four days, but only 2.9% of the dexamethasone group and 4.2% of the prednisolone group were admitted to the hospital at that time. Two weeks after the initial dosing, 5.9% of the dexamethasone group and 4.1% of the prednisolone group were admitted.

Study limitations include the fact that it was a sample of convenience, and there was a lack of blinding in the treating physician, commented Dr. Gordon.

But, given the results, "single-dose IM dexamethasone appears to be as effective as a five-day course of oral prednisolone in the treatment of moderate to severe asthma exacerbations," he told session attendees.

Session moderator Richard John Scarfone, MD, FAAP, from the Children's Hospital of Philadelphia, Pennsylvania, told Medscape that Dr. Gordon's study had the potential to change practice. "The data suggests that dexamethasone might be equally as effective as prednisolone," he said, adding that compliance should be better with the injection.

"I think it still needs a little more study," Rodney Boychuk, MD, FAAP, from the Kapiolani Medical Center for Women and Children in Honolulu, Hawaii, told Medscape, adding that he would not yet suggest a change in practice at his facility. Currently, children are given IM dexamethasone plus a five-day course of steroids at Kapiolani, he said, adding that he'd like that combination to be a third group in any future study.

The findings have led to changes in the emergency department at Children's Hospital in New York, Dr. Gordon told Medscape. Some children can't tolerate prednisolone or may be nauseated and unable to hold down a pill or liquid, he said. But because there were no good data on the steroid's injection effectiveness, physicians were concerned about dosing only with dexamethasone, which tends to be short-acting.

"Most of us now are convinced by this," he said, adding that the injection also is "an advantage in terms of compliance," because physicians cannot be sure whether parents are fully dosing children with oral prednisolone.

Dr. Gordon said he was confident that both oral and injectable steroids are effective for acute exacerbations, despite a paper in the Nov. 1 issue of The Lancet suggesting that a five-day course of oral steroids is no more effective than placebo in reducing symptoms andhospital admissions.

Taking a quick glance at the Lancet paper, Dr. Gordon said that the researchers seemed to have studied a slightly different population, one that did not have prior confirmed asthmatic episodes.

AAP 2003 National Conference and Exhibition: Abstract 204. Presented Oct. 31, 2003.

Reviewed by Gary D. Vogin, MD

Alicia Ault is a freelance writer for Medscape.

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