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Single-Dose Dexamethasone vs 5 Days of Prednisone in Acute Adult Asthma | PracticeUpdate
Disclaimer » Advertising. Erik R. Hoefgen, Bin Huang, Christine L. Schuler, Carolyn M. Hosp Pediatr March ; 12 3 : — Dexamethasone is increasingly used for the management of children hospitalized with asthma in place of prednisone, yet data regarding the effectiveness of dexamethasone in children with asthma exacerbation severe enough to require hospitalization are limited. Our objective is to compare the effectiveness of dexamethasone versus prednisone in children hospitalized with an asthma exacerbation on day reutilization.
A covariate-balanced propensity score was derived to account for physician discretion in steroid selection. A generalized linear model, including inverse probability treatment weighting, was used to detect differences in day return utilization unplanned readmission or emergency department visit between children whose first dose of corticosteroid was dexamethasone versus prednisone. The total cohort had a mean age of 8.
The covariate-balanced cohort had no significant differences in demographic characteristics or illness severity between groups. The dexamethasone group had a return utilization of 3. The propensity score-adjusted analysis revealed the steroid treatment was not found to significantly affect the day reutilization adjusted odds ratio [aOR] 1.
The initial steroid choice dexamethasone versus prednisone was not associated with day reutilization after hospitalization for an asthma exacerbation.
Advertising Disclaimer ». Sign In or Create an Account. Search Close. Shopping Cart. Create Account. Advanced Search. Skip Nav Destination Article Navigation. Close mobile search navigation Article navigation. Volume 12, Issue 3. Previous Article Next Article. Article Navigation. Research Articles February 07 Hoefgen, MD, MS. Louis, Missouri. Louis, MO This Site. Google Scholar. Christine L. Schuler, MD ; Christine L. Schuler, MD. Carolyn M. Kercsmar, MD ; Carolyn M.
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❾-50%}- Dexamethasone versus prednisone
The dosage of dexamethasone in the included studies was 0. Majority studies had an institutional asthma management protocol wherein additional drugs were given to all patients of the trial. Inhaled or nebulized salbutamol, albuterol, and ipratropium bromide were commonly administered in the included studies. The follow-up period ranged from 1 to 15 days. For the meta-analysis, two sub-groups were created based on the follow-up period of relapse rates 1—5 days and 10—15 days.
There was no significant difference in the relapse rate between dexamethasone and prednisone at 1—5 days RR 1. With an overall relapse rate of 8. Sub-group analysis was carried out for 1-day and 2-days dosage of dexamethasone vs.
Figure 2. Forrest plot for dexamethasone vs. Figure 3. Hospital readmission after initial discharge was evaluated by four trials 7 , 13 , 18 , With a re-admission rate of 1. Data on the incidence of vomiting in ED were retrieved from four studies 7 , 13 , 18 , Patients receiving dexamethasone vomited less frequently as compared to prednisone RR 0.
The frequency of vomiting at home was significantly higher with prednisone 5. Figure 4. Figure 5. There was no change in direction of effect size on sensitivity analysis for the variables: relapse rate, hospital readmission, and vomiting at home. However, when the results of Qureshi et al. Figure 7. For the outcome variables, relapse rate and hospital readmission rate, all studies were underpowered. The weighted mean effect size for relapse rate was 0. The power of our meta-analysis for detecting significant difference in relapse rate was For the variables, vomiting at ED and vomiting at home, the weighted mean effect sizes were 0.
The authors' judgment of the risk of bias is presented in Figure 8. Randomization was adequately described in five studies 1 , 13 , 18 , 20 , An appropriate method of allocation concealment was utilized in four trials 1 , 13 , 18 , Only three studies 1 , 18 , 20 provided sufficient information on blinding of participants and personnel while only two trials 1 , 18 reported blinding of outcome assessment. Attrition bias was found to be high in two studies 19 , Figure 8.
Risk of Bias assessment. Green, low risk of bias; Yellow, unclear risk of bias; Red, high risk of bias. Management of acute asthma exacerbations in children not only depends on the therapy provided in the ED but also on strict adherence to medications prescribed on discharge. On the other hand, Butler et al.
Non-compliance to medications on discharge has been attributed to several factors like inadequate funds or lack of insurance, insufficient knowledge on the necessity of treatment, fear of side-effects and prolonged course of treatment 3 , 8 , Dexamethasone, a long-acting corticosteroid, has been studied as an alternative to prednisone to allow a shorter course of treatment in asthmatic patients 4.
While inhaled and single-dose IM dexamethasone may be used as a substitute to prednisone, oral formulation is preferable in managing children 9 , Studies conducted on adult asthmatic patients have found no difference in relapse rates with 2-days oral dexamethasone and 5-days prednisone 24 , Rehrer et al. In our study, while comparing the use of oral dexamethasone and prednisone in pediatric asthma exacerbations, we found no difference in relapse rates between a short-course of dexamethasone as compared to the standard 3—5 days therapy of prednisone.
The hospital readmission rates after initial discharge were slightly higher with dexamethasone as compared to prednisone 1. The results of our study are similar to the previous meta-analyses on this subject. Keeney et al. However, results from both IM and oral dexamethasone trials were pooled in their analysis. Normansell et al. In comparison, while our updated review was able to include three more RCTs, we also conducted a power analysis to identify if the included studies and our meta-analysis was adequately powered to detect significant difference in outcome variables.
It is important to note that despite pooling of data from seven RCTs, our meta-analysis was underpowered to detect significant difference in relapse rates and hospital readmission rates between dexamethasone and prednisone. In a sub-group analysis, we also compared 1-day and a 2-days course of dexamethasone with 3—5 day therapy of prednisone. However, with just one trial reporting a three-way comparison of 1-day and 2-days dexamethasone with prednisone 19 , combined with limited power of our meta-analysis, conclusion cannot be drawn till further studies are carried out to explore the differences between 1 and 2-days dexamethasone protocol.
It is also important to note that relapse rates and hospital readmission rates may be influenced by factors like clinical decisions, hospital criteria for admission and accessibility to healthcare facilities The criteria for relapse rate are also broad varying from the visit of the child to a family doctor for continued wheezing and cough to a severe relapse requiring in-patient management Therefore, objective measures of reduction in asthma severity and assessment of persistent symptoms may better evaluate the differences in the two steroid treatment protocols.
Elkharwili et al. Paniagua et al. PRAM scores were measured at day 4 of treatment by Cronin et al. Altamimi et al. With a mean of 5. While individually all included studies reported dexamethasone to be as efficacious as prednisone, methodological heterogeneity of outcome measures precluded a meta-analysis of such variables in our study.
Despite intra-venous dexamethasone and prednisone demonstrating similar efficacy for preventing nausea and vomiting after chemotherapy 28 , the unpleasant taste of oral prednisone frequently results in vomiting especially in children While the difference of taste between dexamethasone and prednisone has reportedly not been a hindrance in treatment adherence 21 , vomiting may affect treatment compliance in pediatric patients Hames et al.
In our meta-analysis, vomiting at ED and home was found to be significantly higher with prednisone as compared to dexamethasone. Similar results have been reported in the meta-analysis of Keeney et al. The strengths and limitations of our study need to be elaborated.
Firstly, in our review three more RCTs were added since the last published meta-analysis, thereby providing an updated evidence. Secondly, a sensitivity analysis was carried out to assess influence of individual studies on the overall results. Lastly, power analysis was also carried out to provide a guide to readers on the validity of the calculated results.
The results of our review, however, should be interpreted with caution due to the following limitations. Additionally, lack of adequate randomization and allocation concealment, as well as attrition bias in some studies, could have influenced the overall results. Secondly, there was considerable methodological heterogeneity amongst the seven trials especially concerning drug dose, duration of therapy, utilization of additional drugs, follow-up protocol, etc.
Thirdly, inclusion criteria varied amongst studies, with the trial of Paniagua et al. Asthma is usually not diagnosed at such a young age due to the prevalence of bronchiolitis in this age-group Lastly, our meta-analysis was not adequately powered to detect differences in relapse rates and hospital readmission rates, as out of the seven included trials, three studies 1 , 19 , 20 were of small sample size recruiting only 23—51 patients per group.
In our power analysis, all included studies were found to be underpowered for detection of significant difference in the primary outcome variable. To conclude, despite our results indicating similar relapse rates and hospital re-admission rates with dexamethasone and prednisone when used for acute asthmatic exacerbations in children, strong conclusions cannot be drawn due to paucity of large scale RCTs and limited quality of evidence.
It is also not known if both drugs are equally efficacious in reducing asthma severity. Our results however indicate that, vomiting is significantly less with dexamethasone as compared to prednisone. Further large-scale homogenous RCTs comparing the two drugs are warranted to establish guidelines for the use of oral steroid therapy in acute asthma exacerbations in children.
JW and QC conceived and designed the study. JW was involved in the writing of the manuscript. All authors have read and approved the final manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Single-dose oral dexamethasone compared with three day course of oral prednisolone in children with moderate exacerbation of asthma-a pilot double-blinded randomised controlled trial. J Clin Diag Res. Scarfone RJ, Friedlaender E. Corticosteroids in acute asthma: past, present, and future. Pediatr Emerg Care. Different oral corticosteroid regimens for acute asthma. Cochrane Database Syst Rev.
Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Is dexamethasone as effective as prednisone or prednisolone in the management of pediatric asthma exacerbations? Ann Emerg Med. British Guideline on the Management of Asthma. PubMed Abstract Google Scholar. Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. J Pediatr. Butler K, Cooper WO. Adherence of pediatric asthma patients with oral corticosteroid prescriptions following pediatric emergency department visit or hospitalization.
Randomized trial of single-dose intramuscular dexamethasone compared with prednisolone for children with acute asthma. Short report: crushed prednisolone tablets or oral solution for acute asthma? Search for this keyword. Advanced search. Latest content Current issue Archive Authors About. Log in via Institution. You are here Home Archive Volume 27, Issue 3 Two regimens of dexamethasone versus prednisolone for acute exacerbations in asthmatic Egyptian children.
Email alerts. Article Text. Article menu. Original research. Two regimens of dexamethasone versus prednisolone for acute exacerbations in asthmatic Egyptian children. Abstract Introduction Asthma is one of the most prevalent chronic respiratory diseases, which often leads to an emergency department visit.
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Adults presenting to the emergency department with a mild or moderate exacerbation of asthma were randomized to receive a single dose of dexamethasone with 4 days of placebo or 5 days of oral prednisone.
Dexamethasone failed to demonstrate noninferiority to prednisone by a small margin for preventing relapse at 14 days; however, but there were similar rates of hospitalization for relapse and adverse events in the two groups.
The duration of action of dexamethasone is three times as long as that of prednisone and lasts up to 72 hours; 5 mg of prednisone are equal to 0. For adults with an asthma exacerbation, this study randomized patients to a one-time dose of 12 mg of dexamethasone orally followed by 4 days of placebo or 60 mg of prednisone daily for 5 days.
The convenience of this dosing increased compliance, which improves the effectiveness of therapy reducing the cost for treating a relapse. Oral and intramuscular injection of dexamethasone are equivalent. Oral dexamethasone demonstrates bioavailability similar to that of oral prednisone but has a longer half-life.
We evaluate whether a single dose of oral dexamethasone plus 4 days of placebo is not inferior to 5 days of oral prednisone in treatment of adults with mild to moderate asthma exacerbations to prevent relapse defined as an unscheduled return visit for additional treatment for persistent or worsening asthma within 14 days. Adult emergency department patients aged 18 to 55 years were randomized to receive either a single dose of 12 mg of oral dexamethasone with 4 days of placebo or a 5-day course of oral prednisone 60 mg a day.
Outcomes including relapse were assessed by a follow-up telephone interview at 2 weeks. One hundred seventy-three dexamethasone and prednisone subjects completed the study regimen and telephone follow-up. Subjects in the 2 groups had similar rates of hospitalization for their relapse visit dexamethasone 3. Adverse effect rates were generally the same in the 2 groups. A single dose of oral dexamethasone did not demonstrate noninferiority to prednisone for 5 days by a very small margin for treatment of adults with mild to moderate asthma exacerbations.
Enhanced compliance and convenience may support the use of dexamethasone regardless. Property Value Status. We have detected that you are using an Ad Blocker. PracticeUpdate is free to end users but we rely on advertising to fund our site. Please consider supporting PracticeUpdate by whitelisting us in your ad blocker.
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Please update your settings with a valid address before to continue using PracticeUpdate. Close Back. Sign in. Join now. Follow us on:. Search PracticeUpdate Cancel. While a single dose of dexamethasone did not demonstrate noninferiority to 5 days of prednisone for a mild to moderate exacerbation of asthma, outcomes appear comparable and further research may support the use of dexamethasone.
Primary Care Written by. Dexamethasone vs prednisone for asthma flare The duration of action of dexamethasone is three times as long as that of prednisone and lasts up to 72 hours; 5 mg of prednisone are equal to 0. Adult dosing of dexamethasone for various inflammatory conditions: Asthma exacerbation, 12 mg Multiple sclerosis exacerbation, 30 mg Allergic reaction, 8 mg High-altitude cerebral edema, 8 mg References Rehrer MW, Liu B, Rodriguez M, et al.
Ann Emerg Med. A cost-effectiveness analysis of dexamethasone versus prednisone in pediatric acute asthma exacerbations. Acad Emerg Med. This abstract is available on the publisher's site. METHODS Adult emergency department patients aged 18 to 55 years were randomized to receive either a single dose of 12 mg of oral dexamethasone with 4 days of placebo or a 5-day course of oral prednisone 60 mg a day.
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localhost › GoodRx Health › Drug Classes › Corticosteroids. Dexamethasone is long-acting medication and is considered to be a potent, or strong, steroid. It is 6 times more potent (strong) than prednisone. Can prednisone. Findings of this meta-analysis shows that DEX is better than PRED in tolerability and as efficacious as PRED, which indicates that DEX is a suitable alternative. Prednisolone is the most commonly used corticosteroid in treatment of asthma exacerbation. Oral dexamethasone demonstrates bioavailability similar to that of. Dexamethasone's favorable side effect profile and pharmacokinetics compared with prednisone may mitigate poor adherence to longer steroid. This site uses cookies. Institutional Login. The convenience of this dosing increased compliance, which improves the effectiveness of therapy reducing the cost for treating a relapse. The information above is a helpful comparison between the two drugs. J Clin Diag Res.Background: This systematic review and meta-analysis was conducted to compare relapse rates and adverse effects with oral dexamethasone vs. Dosage of dexamethasone and prednisone varied across studies. Studies were grouped based on the follow-up period and duration of dexamethasone administration. Results: There was no significant difference in the relapse rate between dexamethasone and prednisone at 1—5 days RR 1.
Pooled analysis found no significant difference in relapse rates with 1-day RR 1. Hospital readmission rates after initial discharge were not significantly different between the two drugs RR 1. Frequency of vomiting at ED RR 0. Conclusion: While our results indicate that both dexamethasone and prednisone have similar relapse rates when used for acute asthmatic exacerbations, strong conclusions cannot be drawn due to paucity of large scale RCTs and limited quality of evidence.
Dexamethasone is however associated with lower incidence of vomiting as compared to prednisone. Further homogenous RCTs are needed to provide robust evidence on this topic. Asthma is a common pediatric disease that results in significant limitation of activity and an estimated loss of The disease is characterized by chronic airway inflammation, airway edema, bronchoconstriction, and airway hyperresponsiveness which results in respiratory symptoms like wheezing, shortness of breath, chest tightness, and cough 2.
The intensity of the disease varies with time and episodes of exacerbation frequently require management in the pediatric Emergency Department ED 3. The primary line of treatment in acute exacerbations of asthma is directed at a quick reversal of bronchospasm and reduction of airway inflammation 4.
For this purpose, oral steroids are extremely effective for alleviating symptoms in children 5. Early use of oral steroid therapy is also recommended with prednisone being the drug of choice 6. Relapse after prednisone therapy has been attributed to several factors like the unpleasant bitter taste of the drug, side-effects like vomiting, and its multi-dose regimen of 3—5 days which may reduce patient compliance 8 — To improve patient compliance and reduce relapse rates, the role of dexamethasone has been evaluated in many trials 4 , 7.
Initial studies evaluating a single dose of intramuscular IM dexamethasone have found it to be as effective as a 3—5 day regimen of prednisone 11 , Subsequently, studies have also compared oral 1 or 2-day therapy of dexamethasone against a 3—5 days regimen of oral prednisone 4 , Oral formulations are desirable in children as they are associated with less pain.
To date, two meta-analyses have compared oral dexamethasone and prednisone for acute exacerbations of asthma in children, with the last literature search performed in April 3 , 4. Due to the limited number of studies analyzed in these previous reviews, this study aimed to provide an updated Level 1 evidence on relapse rates and adverse effects of oral dexamethasone vs.
Studies including adult asthma patients and utilizing the parenteral route of administration of dexamethasone or prednisone were excluded. We also excluded non-randomized studies, retrospective studies, case-series, and non-English language studies.
The last literature search was conducted on 1st August After assessing the studies by their titles and abstracts, full-texts of selected articles were retrieved. Both the reviewers assessed individual studies based on inclusion criteria.
Disagreements, if any, were resolved by mutual agreement. Using an abstraction form, two reviewers retrieved data from selected studies. The primary outcome was the relapse rate defined by an unscheduled visit to the ED or clinic. Secondary outcomes were hospital readmission after discharge and incidence of vomiting at ED or home.
Every study was evaluated for the following variables: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases. We rated studies on each variable as low risk, high risk, or unclear risk of bias. Anticipating heterogeneity amongst studies, a random-effects model was used to calculate the pooled effect size.
Heterogeneity was calculated using the I 2 statistic. A sensitivity analysis was carried out to assess the influence of each study on the pooled effect size. Sub-group analysis was conducted for relapse rates based on follow-up period 1—5 days or 10—15 days and dosage of dexamethasone.
Using the method described by Muncer et al. Gpower software was used to calculate the power of studies. Out of the potentially relevant articles, 10 were selected for full-text analysis Figure 1.
Three studies evaluated intramuscular dexamethasone vs. A total of seven unique articles were included in this systematic review and meta-analysis 1 , 7 , 13 , 18 — Details of individual studies are presented in Table 1. All trials included pediatric patients, however, the age group varied across studies. All studies were performed in the ED with varying sample sizes 23— patients.
One study excluded patients with severe asthma exacerbation One included patients with moderate severity of exacerbation only 1 while another study included patients with moderate to severe exacerbations Asthma severity was measured on different scales across trials.
With an exception of one study 20 , there was no statistical significant difference between asthma severity scores of the two study groups. Dexamethasone was administered as a 1-day 1 , 13 , 18 or 2-days therapy 7 , 20 , In one trial, patients were randomized into three groups of 1-day dexamethasone, 2-days dexamethasone, and prednisone Data of both dexamethasone groups were compared separately with prednisone in our meta-analysis.
The dosage of dexamethasone in the included studies was 0. Majority studies had an institutional asthma management protocol wherein additional drugs were given to all patients of the trial. Inhaled or nebulized salbutamol, albuterol, and ipratropium bromide were commonly administered in the included studies.
The follow-up period ranged from 1 to 15 days. For the meta-analysis, two sub-groups were created based on the follow-up period of relapse rates 1—5 days and 10—15 days. There was no significant difference in the relapse rate between dexamethasone and prednisone at 1—5 days RR 1. With an overall relapse rate of 8. Sub-group analysis was carried out for 1-day and 2-days dosage of dexamethasone vs.
Figure 2. Forrest plot for dexamethasone vs. Figure 3. Hospital readmission after initial discharge was evaluated by four trials 7 , 13 , 18 , With a re-admission rate of 1. Data on the incidence of vomiting in ED were retrieved from four studies 7 , 13 , 18 , Patients receiving dexamethasone vomited less frequently as compared to prednisone RR 0. The frequency of vomiting at home was significantly higher with prednisone 5. Figure 4. Figure 5. There was no change in direction of effect size on sensitivity analysis for the variables: relapse rate, hospital readmission, and vomiting at home.
However, when the results of Qureshi et al. Figure 7. For the outcome variables, relapse rate and hospital readmission rate, all studies were underpowered. The weighted mean effect size for relapse rate was 0. The power of our meta-analysis for detecting significant difference in relapse rate was For the variables, vomiting at ED and vomiting at home, the weighted mean effect sizes were 0.
The authors' judgment of the risk of bias is presented in Figure 8. Randomization was adequately described in five studies 1 , 13 , 18 , 20 , An appropriate method of allocation concealment was utilized in four trials 1 , 13 , 18 , Only three studies 1 , 18 , 20 provided sufficient information on blinding of participants and personnel while only two trials 1 , 18 reported blinding of outcome assessment. Attrition bias was found to be high in two studies 19 , Figure 8.
Risk of Bias assessment. Green, low risk of bias; Yellow, unclear risk of bias; Red, high risk of bias. Management of acute asthma exacerbations in children not only depends on the therapy provided in the ED but also on strict adherence to medications prescribed on discharge.
On the other hand, Butler et al. Non-compliance to medications on discharge has been attributed to several factors like inadequate funds or lack of insurance, insufficient knowledge on the necessity of treatment, fear of side-effects and prolonged course of treatment 3 , 8 , Dexamethasone, a long-acting corticosteroid, has been studied as an alternative to prednisone to allow a shorter course of treatment in asthmatic patients 4.
While inhaled and single-dose IM dexamethasone may be used as a substitute to prednisone, oral formulation is preferable in managing children 9 , Studies conducted on adult asthmatic patients have found no difference in relapse rates with 2-days oral dexamethasone and 5-days prednisone 24 , Rehrer et al.
In our study, while comparing the use of oral dexamethasone and prednisone in pediatric asthma exacerbations, we found no difference in relapse rates between a short-course of dexamethasone as compared to the standard 3—5 days therapy of prednisone.
The hospital readmission rates after initial discharge were slightly higher with dexamethasone as compared to prednisone 1.
The results of our study are similar to the previous meta-analyses on this subject. Keeney et al. However, results from both IM and oral dexamethasone trials were pooled in their analysis.
Normansell et al.
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