Dexamethasone for Asthma
Reactive 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.
- High-dose inhaled corticosteroids are not effective in severe exacerbations. (Henedeles, 2003)
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.
[…] Fox at PED EM Morsels discusses the question of which steroids are better for asthma – dex or pred? […]
That was a nice review of the recent literature. We know steroids given early in the illness improve outcomes for patients. But when it comes to writing the order for the medication, the devil is in the details. Which med? What dose? How long to treat? We face decisions on which medication, how much of it, how often to give it, and how long to give it for. This takes the reflexively simple choice to give steroids and changes it in to a complicated mess of uncertainty.
Dexamethasone also comes at tablets that can be crushed. Are you using that option?
You are correct. This is another viable option to keep in mind.
Thank you,
sean
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
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
[…] Dexamethasone for Asthma – … – 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 … […]
[…] making this choice? Which is the most cost effective? Findings from a few different studies are summarised here by […]
Great! nice sense of humor.
Essential
revision notes for MRCP phillip kalara
[…] Fox at PED EM Morsels discusses the question of which steroids are better for asthma – dex or pred? […]
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
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
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