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#162 Dexamethasone Versus Prednisone for Pediatric Asthma: Will the results take your breath away?


CLINICAL QUESTION
QUESTION CLINIQUE
Are 1-2 doses of dexamethasone as effective as the standard five day prednisone regimen for treatment of pediatric asthma exacerbations?


BOTTOM LINE
RÉSULTAT FINAL
Treatment of pediatric asthma exacerbations with short-course dexamethasone (0.6 mg/kg x 1-2 doses) is a safe and effective alternative to traditional five day courses of prednisoneFor every ~20 children treated with dexamethasone, there will be one less vomited dose



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EVIDENCE
DONNÉES PROBANTES
  • Systematic review of six Randomized Controlled Trials (RCTs) of pediatric asthma exacerbations: 1-2 doses of oral/intramuscular dexamethasone versus daily oral prednisone x5 days.1 
    • No difference in relapse rates (visit to Emergency Department (ED), clinic, or hospitalization) at any time.   
    • Dexamethasone statistically significantly reduced vomiting in ED: 1.2versus 5.3, Number Needed to Treat (NNT)=25.   
      • Also, NNT=26 vomiting at home. 
    • Limitations of systematic reviewStudy heterogeneity (dosages and routes of administration)most RCTs small, not blinded. 
    • Largest RCT in systematic review: 628 children aged 2-18 years with ED asthma exacerbation.2 Oral dexamethasone 0.6 mg/kg/day x2 days versus oral prednisone 2 mg/kg/day x5 days. 
      • No difference in relapse, symptom improvement or re-hospitalization at day 10. 
  • 2015 RCT not in systematic review: 245 children aged 2-17 years with ED asthma exacerbation.3 Single dose oral dexamethasone 0.3 mg/kg versus oral prednisolone 1 mg/kg/d x3 days.  
    • No difference: 
      • Primary outcome: Day four Pediatric Respiratory Assessment Measure0.91 versus 0.91. 
      • Hospital admission, length of admission, return to care, number of school or parental work days missed. 
    • Vomiting of first dose: 0% dexamethasone versus 5.7% prednisolone, NNT=18. 
Context: 
  • Systemic corticosteroids (versus placebo) for asthma exacerbations within one hour of ED presentation decreases hospital admissions (NNT=8).4  
  • In a palatability study, liquid dexamethasone scored 8.2 (out of 10, higher better) versus 5.0 for liquid prednisolone.5 
  • Two studies6,7 report that 79-88% of caregivers prefer 1-2 day over five day courses of steroids 
  • Injectable dexamethasone solution may be given orally. Elixir (0.5 mg/ml) available by prescription.8,9 
  • The Canadian Pediatric Society lists both prednisone/prednisolone and dexamethasone as options for acute pediatric asthma exacerbations.10 


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Author(s)
Auteur(s)
  • Cathy Dewaal BScPharm
  • Christina Korownyk MD CCFP

1. Keeney GE, Gray MP, Morrison AK, et al. Pediatrics. 2014; 133(3):493-9.

2. Qureshi F, Zaritsky A, Poirier MP. J Pediatr. 2001; 139(1):20-6.

3. Cronin JJ, McCoy S, Kennedy U, et al. Ann Emerg Med. October 2015. pii: S0196-0644(15)01154-3. [Epub ahead of print]

4. Rowe BH, Spooner C, Ducharme FM, et al. Cochrane Database Syst Rev. 2001; (1):CD002178.

5. Hames H, Seabrook JA, Matsui D, et al. Can J Clin Pharmacol. 2008; 15(1):95-8.

6. Williams KW, Andrews AL, Heine D, et al. Clin Pediatr (Phila). 2013; 52(1):30-4.

7. Szlam S, Arnold DH. Clin Pediatr (Phila). 2015 Jan; 54(1):15-8.

8. CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2015 [updated 2011 Oct; cited 2016 Jan 23]. Corticosteroids; Systemic [CPhA monograph]. Available at: http://www.e-therapeutics.ca. Also available in paper copy from the publisher.

9. Can kids be given injectable dexamethasone orally? Available at: http://www.medscape.com/viewarticle/758927. Last accessed February 8, 2016.

10. Ortiz-Alvarez O, Mikrogianakis A; Canadian Paediatric Society, Acute Care Committee. Paediatr Child Health. 2012 May; 17(5):251-62.

Authors do not have any conflicts to disclose.