Dexamethasone for Asthma

Get CMEDexamethasoneALIEM AIR Certified LogoReactive 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

Keeney GE1, Gray MP, Morrison AK, Levas MN, Kessler EA, Hill GD, Gorelick MH, Jackson JL. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014 Mar;133(3):493-9. PMID: 24515516. [PubMed] [Read by QxMD]

Williams KW1, Andrews AL, Heine D, Russell WS, Titus MO. Parental preference for short- versus long-course corticosteroid therapy in children with asthma presenting to the pediatric emergency department. Clin Pediatr (Phila). 2013 Jan;52(1):30-4. PMID: 23034948. [PubMed] [Read by QxMD]

Andrews AL1, Wong KA, Heine D, Scott Russell W. A cost-effectiveness analysis of dexamethasone versus prednisone in pediatric acute asthma exacerbations. Acad Emerg Med. 2012 Aug;19(8):943-8. PMID: 22849379. [PubMed] [Read by QxMD]

Greenberg RA1, Kerby G, Roosevelt GE. A comparison of oral dexamethasone with oral prednisone in pediatric asthma exacerbations treated in the emergency department. Clin Pediatr (Phila). 2008 Oct;47(8):817-23. PMID: 18467673. [PubMed] [Read by QxMD]

Hames H1, Seabrook JA, Matsui D, Rieder MJ, Joubert GI. A palatability study of a flavored dexamethasone preparation versus prednisolone liquid in children. Can J Clin Pharmacol. 2008 Winter;15(1):e95-8. PMID: 18245869. [PubMed] [Read by QxMD]

Volovitz B1, Bilavsky E, Nussinovitch M. Effectiveness of high repeated doses of inhaled budesonide or fluticasone in controlling acute asthma exacerbations in young children. J Asthma. 2008 Sep;45(7):561-7. PMID: 18773327. [PubMed] [Read by QxMD]

National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007 Nov;120(5 Suppl):S94-138. PMID: 17983880. [PubMed] [Read by QxMD]

Hendeles L1, Sherman J. Are inhaled corticosteroids effective for acute exacerbations of asthma in children? J Pediatr. 2003 Feb;142(2 Suppl):S26-32; discussion S32-3. PMID: 12584517. [PubMed] [Read by QxMD]

Qureshi F1, Zaritsky A, Poirier MP. Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. J Pediatr. 2001 Jul;139(1):20-6. PMID: 11445789. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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9 Responses

  1. Aaron Leetch says:

    Excellent morsel this month, Sean. I have this discussion a fair amount with my residents as I have seen many give Dex instead of pred. I’ll be honest that I’m on the pred side for a couple of reasons:

    -I use prednisolone as it’s equipotent and tastes like cherries
    -We use the IV form of dex (1mg/0.1mL?) orally in the ED but have no similar option to give outpt for the second dose. In fact, the only liquid option I have is 0.5mg/5mL. And trying to get a kid to take a crushed up pill? That’s why we invented liquid medicine.

    Curious of your thoughts. I haven’t reviewed the articles about single dose dex but I’ll be sure to do so.

    Aaron

  2. Aaron Leetch says:

    Excellent morsel this month, Sean. I have this discussion a fair amount with my residents as I have seen many give Dex instead of pred. I’ll be honest that I’m on the pred side for a couple of reasons:

    -I use prednisolone as it’s equipotent and tastes like cherries
    -We use the IV form of dex (1mg/0.1mL?) orally in the ED but have no similar option to give outpt for the second dose. In fact, the only liquid option I have is 0.5mg/5mL. And trying to get a kid to take a crushed up pill? That’s why we invented liquid medicine.

    Curious of your thoughts. I haven’t reviewed the articles about single dose dex but I’ll be sure to do so.

    Aaron

    • Sean Fox says:

      Dr. Leetch,
      I appreciate your comments and patronage!

      I agree that ordering the home dose of Dexamethasone can be tricky. We also typically use the IV formulation of the medicine given in an oral manner. This allows for a much smaller amount to be given (which is generally appreciated by the kids).

      Naturally, this is only an issue with respect to prescribing to patients who won’t take pills. I have been surprised at how many times I have incorrectly judged this (on both sides of the equation).

      While prednisolone may taste better than prednisone, the issue is still in that it has to be taken for several days. Personally, I’d rather not have to prescribe any medication that has to be taken after the patient leaves, as this allows too many variables to enter into the equation of compliance.

      So, the real question is, if you can achieve good results with one dose, than why choose 5? The literature supports a single dose (or two doses of dexamethasone).

      Personally, I choose the longer duration of prednisolone if the child has a more difficult and complicate history and may, in the end, need a steroid taper.

      Thank you again!
      Have a Great New Year,
      sean

  3. Casey Parker says:

    Thanks Sean
    We have a 1mg/ml oral Dex syrup in Australia
    It tastes sweet, but a little bitter aftertaste
    I reckon this is awinner in my shop- compliance is a big issue, this fixes that

    • Sean Fox says:

      Casey,
      Life can be be both bitter and sweet! 😉

      We use the IV formulation given orally… it seems to be well tolerated and effective.

      Thanks for your insight,
      Sean

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