Giving children with acute asthma flare-ups 1 or 2 doses of dexamethasone in the emergency department (ED) provides equivalent relief to a 5-day course of prednisone while reducing the chance of triggering vomiting, according to a meta-analysis by Grant E. Keeney, MD, from the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and colleagues, who published the results of their analysis online February 10 in Pediatrics.
Some 6 million children in the United States suffer from asthma, a chronic inflammatory disease that accounts for 2% of all ambulatory care and ED visits by pediatric patients, the authors write. Oral prednisone, which tamps down inflammation and decreases mucus production, is the cornerstone of treatment for acute asthma exacerbations, but the remedy exacts a cost: vomiting.
The authors sought to determine whether dexamethasone might provide the same therapeutic benefit with fewer doses and less vomiting than is associated with a 5-day course of oral prednisone or prednisolone. Searching PubMed, the researchers identified 667 articles describing randomized clinical trials comparing the medicines of interest; they included 6 trials in the meta-analysis.
Each study was performed in the ED and enrolled from 15 to 272 patients, 63.5% of whom were boys. Dexamethasone was given as a single dose, either orally or intramuscularly, in 4 studies and was given as multiple doses in 2 studies. There was no statistically significant difference between the 2 therapies when it came to relapses to the clinic, ED, or hospitalization.
"Significantly fewer patients receiving dexamethasone vomited in the ED or at home after discharge. This finding has clinical significance for improving patient and parental satisfaction," according to the authors.
"This is a huge win for those of us in emergency medicine and, more importantly, for the families we take care of, when you consider that asthma is the most common chronic disease of children," Stephen J. Teach, MD, MPH, associate chief of the Division of Emergency Medicine at Children's National Medical Center in Washington, DC, told Medscape Medical News.
According to Dr. Teach, the facility handles 1% of ED visits made by children in the country for asthma. Practitioners recognized that if prednisone was given as early as possible during a significant asthma flare-up, it cut down on emergency admissions, and children missed less school.
"It was big breakthrough," he told Medscape Medical News. However, "prednisone is a terrible medication to take. It tastes awful. It's hard to mask it.... When it hits the stomach, it's an irritant. Kids throw it up all the time. It became this wonderful–terrible thing."
Dexamethasone's noxious taste, in contrast, can be masked with cherry syrup. Large-volume EDs already have begun to make the shift.
"There's really no difference, and it's more patient-centered," said Dr. Teach, who was not involved in the current study. "Kids take it better. They take fewer doses.... All of the available data suggest there is no difference in short-term outcomes."
The authors note that their results were based on studies based in the ED, making it unclear whether they apply to the ambulatory clinic setting.
"Based on our findings, emergency physicians should consider single or 2-dose dexamethasone regimens over 5-day prednisone/prednisolone regimens for the treatment of acute asthma exacerbations," the authors conclude.
Support for this study was provided by the National Center for Advancing Translational Sciences, National Institutes of Health. The authors and Dr. Teach have disclosed no relevant financial relationships.
Pediatrics. Published online February 10, 2014.
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Cite this: Dexamethasone Tames Acute Asthma in Kids, With Less Vomiting - Medscape - Feb 10, 2014.