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Kramer AW, Erlich J, Yaphockun K, Roderick D, Farkas K, Bryl AW, Pade KH. Reducing Time from Pediatric Emergency Department Arrival to Dexamethasone Administration in Wheezing Patients. Pediatr Qual Saf 2024; 9:e738. [PMID: 38868756 PMCID: PMC11167218 DOI: 10.1097/pq9.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024] Open
Abstract
Introduction Asthma exacerbations are common presentations to pediatric emergency departments. Standard treatment for moderate-to-severe exacerbations includes administration of oral corticosteroids concurrently with bronchodilators. Early administration of corticosteroids has been shown to decrease emergency department length of stay (LOS) and hospitalizations. Our SMART aim was to reduce the time from arrival to oral corticosteroids (dexamethasone) administration in pediatric patients ≥2 years of age with an initial Pediatric Asthma Severity Score >6 from 60 to 30 minutes within 6 months. Methods We used the model for improvement with collaboration between ED physicians, nursing, pharmacy, and respiratory therapists. Interventions included nursing education, dosage rounding in the electronic medical record, supplying triage with 1-mg tablets and a pill crusher, updates to an asthma nursing order set and pertinent chief complaints triggering nurses to document a Pediatric Asthma Severity Score in the electronic medical record and use the order set. Our primary outcome measure was the time from arrival to dexamethasone administration. Secondary outcome measures included ED LOS for discharged patients and admission rate. We used statistical process control to analyze changes in measures over time. Results From October 2021 to March 2022, the average time for dexamethasone administration decreased from 59 to 38 minutes. ED LOS for discharged asthma exacerbation patients rose with overall ED LOS for all patients during the study period. There was no change in the admission rate. Conclusions Using quality improvement methodology, we successfully decreased the time from ED arrival to administration of dexamethasone in asthma exacerbation patients from 59 to 38 minutes over 10 months.
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Roddy MR, Sellers AR, Darville KK, Teppa-Sanchez B, McKinley SD, Martin M, Goldenberg NA, Nakagawa TA, Sochet AA. Dexamethasone versus methylprednisolone for critical asthma: A single center, open-label, parallel-group clinical trial. Pediatr Pulmonol 2023; 58:1719-1727. [PMID: 36929864 DOI: 10.1002/ppul.26386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Evidence for the use of dexamethasone for pediatric critical asthma is limited. We sought to compare the clinical efficacy and safety of dexamethasone versus methylprednisolone among children hospitalized in the pediatric intensive care unit (PICU) for critical asthma. METHODS A prospective, single center, open-label, two-arm, parallel-group, nonrandomized trial among children ages 5-17 years hospitalized within the PICU from April 2019 to December 2021 for critical asthma consented to receive methylprednisolone (standard care) or dexamethasone (intervention) at a 2:1 allocation ratio, respectively. The intervention arm received intravenous dexamethasone 0.25 mg/kg/dose (max: 15 mg/dose) every 6 h for 48 h and the standard care arm intravenous methylprednisolone 1 mg/kg/dose every 6 h (max dose: 60 mg/dose) for 5 days. Study endpoints were clinical efficacy (i.e., length of stay [LOS], continuous albuterol duration, and a composite of adjunctive asthma interventions) and safety (i.e., corticosteroid-related adverse events). RESULTS Ninety-two participants were analyzed of whom 31 were allocated to the intervention arm and 61 the standard care arm. No differences in demographics, clinical characteristics, or acute/chronic asthma severity indices were observed. Regarding efficacy and safety endpoints, no differences in hospital LOS, continuous albuterol duration, adjunctive asthma intervention rates, or corticosteroid-related adverse events were noted. Compared to the intervention arm, participants in the standard care arm more frequently were prescribed corticosteroids at discharge (72% vs. 13%, p < 0.001). CONCLUSIONS Among children hospitalized for critical asthma, dexamethasone appears safe and warrants further investigation to fully assess clinical efficacy and potential advantages over commonly applied agents such as methylprednisolone.
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Affiliation(s)
- Meghan R Roddy
- Departments of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Austin R Sellers
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Kristina K Darville
- Departments of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Beatriz Teppa-Sanchez
- Departments of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Scott D McKinley
- Departments of Pulmonlogy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Meghan Martin
- Departments of Emergency Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Departments of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Departments of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas A Nakagawa
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Florida-Jacksonville, Jacksonville, Florida, USA
| | - Anthony A Sochet
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Departments of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Dahan E, El Ghazal N, Nakanishi H, El Haddad J, Matar RH, Tosovic D, Beran A, Than CA, Stiasny D. Dexamethasone versus prednisone/prednisolone in the management of pediatric patients with acute asthmatic exacerbations: a systematic review and meta-analysis. J Asthma 2022:1-12. [PMID: 36461938 DOI: 10.1080/02770903.2022.2155189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
OBJECTIVE Acute asthmatic exacerbation is a common condition for pediatric emergency visits. Recently, dexamethasone has increasingly been used as an alternative to prednisone. This study aimed to evaluate the safety and efficacy of dexamethasone (DEX) against prednisone/prednisolone (PRED) in managing pediatric patients with acute asthmatic exacerbation. DATA SOURCES Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to August 2022 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42022353462). STUDY SELECTIONS From 316 studies screened, seventeen studies met the eligibility criteria, with 5967 pediatric patients experiencing an asthma exacerbation requiring treatment with either DEX (n = 2865) or PRED (n = 3102). Baseline patient characteristics (age, sex, PRAM (pediatric respiratory assessment measure), previous corticosteroid and beta-agonist inhaler) were comparable between groups. RESULTS After treatment administration, the DEX group had fewer vomiting incidents (OR = 0.24, 95% CI: 0.11, 0.51, I2 = 58%) and reduced noncompliance events (OR = 0.12, 95% CI: 0.04, 0.34, I2 = 0%) when compared to the PRED group. Regarding emergency-department (ED)-related outcomes, there were no differences in hospital admission rates (OR = 0.83, 95% CI: 0.58, 1.19, I2 = 15%), time spent in the ED (MD= -0.11 h, 95% CI: -0.52; 0.30, I2 = 82%) or relapse occurrences (OR = 0.67, 95% CI: 0.30, 1.49, I2 = 52%) between both groups. CONCLUSION Although there were no differences between the DEX and PRED groups in terms of hospital admission rates, time spent in the ED or relapse events, pediatric patients receiving DEX experienced lower noncompliance and vomiting rates.
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Affiliation(s)
- Elise Dahan
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Nour El Ghazal
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Hayato Nakanishi
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Joe El Haddad
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Reem H Matar
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus.,Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Danijel Tosovic
- School of Biomedical Sciences, The University of Queensland, St Lucia, Australia
| | - Azizullah Beran
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Christian A Than
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus.,School of Biomedical Sciences, The University of Queensland, St Lucia, Australia
| | - David Stiasny
- Pediatrics Department Swedish Medical Group, Chicago, IL, USA
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4
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Effectiveness of single dose oral dexamethasone versus multidose prednisolone for treatment of acute exacerbations of asthma among children. Ann Med Surg (Lond) 2022; 84:104799. [DOI: 10.1016/j.amsu.2022.104799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/23/2022] [Indexed: 11/09/2022] Open
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5
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Bakel LA, Richardson T, De Souza HG, Kaiser SV, Mahant S, Treasure JD, Waynik IY, Winer JC, Bajaj L. Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions. J Hosp Med 2022; 17:417-426. [PMID: 35535935 DOI: 10.1002/jhm.12811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions. OBJECTIVE Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes. DESIGNS We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database. SETTINGS AND PARTICIPANTS We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis. INTERVENTION We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital. MAIN OUTCOME AND MEASURES The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions. RESULTS Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions. CONCLUSION We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs.
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Affiliation(s)
- Leigh Anne Bakel
- Section of Hospital Medicine, Department of Pediatrics, Clinical Effectiveness Team, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | - Sunitha V Kaiser
- Department of Pediatrics, University of California at San Francisco, San Francisco, California, USA
| | - Sanjay Mahant
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Jennifer D Treasure
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ilana Y Waynik
- Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut, Mansfield, Connecticut, USA
| | - Jeffrey C Winer
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lalit Bajaj
- Section of Hospital Medicine, Department of Pediatrics, Clinical Effectiveness Team, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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Martin M, Penque M, Wrotniak BH, Qiao H, Territo H. Single-Dose Dexamethasone Is Not Inferior to 2 Doses in Mild to Moderate Pediatric Asthma Exacerbations in the Emergency Department. Pediatr Emerg Care 2022; 38:e1285-e1290. [PMID: 35507383 DOI: 10.1097/pec.0000000000002727] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the efficacy of a single dose of dexamethasone to 2 doses of dexamethasone in treating mild to moderate asthma exacerbations in pediatric patients. We anticipated that there would not be a difference in the rate of return visits to the emergency department (ED), urgent care, or primary care physician for continued asthma symptoms. METHODS This was a prospective, randomized, single-center, unblinded, parallel-group randomized clinical trial of patients 2 to 20 years old presenting to a pediatric ED with mild to moderate asthma exacerbations. The patients were randomized to receive 1 or 2 doses of dexamethasone (0.6 mg/kg per dose, maximum of 16 mg). Telephone follow-up interviews were performed on the sixth day after ED visit. The primary outcome measures were return visits to either primary care physician or ED for continued asthma symptoms. Secondary outcomes were days of symptoms, missed school days, and adverse effects. RESULTS Of the 318 children initially enrolled, 308 patients met the enrollment criteria. These patients were randomized into 2 groups. There were 116 patients in group 1 and 116 patients in group 2. There was no significant difference between groups regarding return visits (group 1, 12.1%; group 2, 10.3%; odds ratio [OR], 0.892 [95% confidence interval {CI}, 0.377-2.110]), days to symptom resolution (group 1, 2.4; group 2, 2.5; OR, 0.974 [95% 95% CI, 0.838-1.132]), missed school days (group 1, 47%; group 2, 51%; OR, 1.114 [95% CI, 0.613-2.023]), or vomiting (group 1, 8.6%; group 2, 3.4%; OR, 2.424 [95% CI, 0.637-9.228]). CONCLUSIONS In this single-center, unblinded randomized trial of children and adolescents with mild to moderate acute exacerbations of asthma, there was no difference in the rate of return visits for continued or worsened symptoms between patients randomized to 1 or 2 doses of dexamethasone.
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Affiliation(s)
- Meghan Martin
- From the Division of Emergency Medicine, Department of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Michelle Penque
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, NY
| | - Brian H Wrotniak
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, NY
| | - Haiping Qiao
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, NY
| | - Heather Territo
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, NY
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7
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Sonnenberg LK, Sinclair D. A Randomized Controlled Study Addressing Dexamethasone Tolerability in the Treatment of Acute Asthma in Children: Mary Poppins on Trial! J Pharm Pract 2022:8971900221076447. [PMID: 35341362 DOI: 10.1177/08971900221076447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM Emesis of oral medications continues to be a problem in the management of acute pediatric asthma exacerbations; therefore, we set out to assess whether smaller volumes of oral dexamethasone resulted in better tolerability. METHODS Children aged 2-14 years, presenting to the emergency department with acute asthma exacerbation, were enrolled in this open, prospective randomized controlled trial. Participants received 0.3 mg/kg of dexamethasone in either its concentrated volume (10 mg/mL) or mixed with Ora Sweet (1 mg/mL). Tolerability was measured by vomiting within 45 minutes of receiving dexamethasone, with stratification, a priori, for prior vomiting. RESULTS 430 participants were enrolled. 23/213 (11%) in the 10 mg/mL group vomited dexamethasone compared to 16/217 (7%) in the 1 mg/mL group (P = .29). 11/179 (6%) in the 10 mg/mL group vomited compared to 8/183 (3%) in the 1 mg/mL group (.61). For those 68 stratified with prior vomiting, 12/34 (35%) in the 10 mg/mL group vomited compared to 8/34 (24%) in the 1 mg/mL group (P = .43). None of these results were statistically different. Prior vomiting increased the risk of vomiting, regardless of the formulation given (P < .001). CONCLUSIONS Volume does not play a significant role in the tolerability of dexamethasone. Therefore, palatability should not be sacrificed for a smaller volume of dexamethasone to improve tolerability.
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Affiliation(s)
| | - Douglas Sinclair
- Department of Emergency Medicine, 3682IWK Health Centre and Dalhousie University, Halifax, NS, Canada
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8
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Sellers AR, Roddy MR, Darville KK, Sanchez-Teppa B, McKinley SD, Sochet AA. Dexamethasone for Pediatric Critical Asthma: A Multicenter Descriptive Study. J Intensive Care Med 2022; 37:1520-1527. [PMID: 35236174 DOI: 10.1177/08850666221082540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Systemic corticosteroids are vital to critical asthma management. While intravenous methylprednisolone is routinely used in the pediatric intensive care unit (PICU) setting, recent data supports dexamethasone as an alternative. Using the Pediatric Health Information System (PHIS) registry, we assessed trends and variation in corticosteroid prescribing among children hospitalized for critical asthma. METHODS We performed a multicenter retrospective cohort study using PHIS data among children 3-17 years of age admitted for critical asthma from 2011 through 2019. Primary outcomes were corticosteroid prescribing rates by year and participating sites. Exploratory outcomes were corticosteroid-related adverse effects, rates of adjunctive pharmaceutical and respiratory interventions, mortality and length of stay. RESULTS Of the 49 children's hospitals assessed, 26 907 encounters were included for study. Mean dexamethasone exposure rates were 18.1 ± 2.4% where 2.4 ± 1.2% represented dexamethasone-alone prescribing. Dexamethasone alone prescribing exhibited a linear trend (annual increase of 0.5 ± 0.1% annually R2 = 0.845) without correlation to cumulative site critical asthma admission rates. Compared to encounters prescribed solely methylprednisolone or a combination of dexamethasone and methylprednisolone, subjects provided dexamethasone alone had reduced asthma severity indices, length of stay, and exposure rates to adjunctive asthma interventions. Adverse events were rare and the dexamethasone-alone group less frequently experienced gastritis and hyperglycemia. CONCLUSIONS In this multicenter retrospective study from 49 children's hospitals, dexamethasone prescribing rates appear increasing for pediatric critical asthma. Observed variability in corticosteroid prescribing implies a continued need for controlled prospective comparative analyses to define ideal corticosteroid regimens for pediatric critical asthma.
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Affiliation(s)
- Austin R Sellers
- Institute for Clinical and Translational Research, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Meghan R Roddy
- Department of Pharmacy, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Kristina K Darville
- Department of Medicine, Division of Pediatric Critical Care Medicine, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Beatriz Sanchez-Teppa
- Department of Medicine, Division of Pediatric Critical Care Medicine, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Scott D McKinley
- Department of Medicine, Division of Pediatric Pulmonology and Sleep Medicine, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Anthony A Sochet
- Institute for Clinical and Translational Research, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Medicine, Division of Pediatric Critical Care Medicine, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Anesthesiology and Critical Care Medicine, 1500Johns Hopkins University School of Medicine, Baltimore, MD, USA
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9
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Hatoun J, Correa ET, MacGinnitie AJ, Gaffin JM, Vernacchio L. Development and Validation of the Asthma Exacerbation Risk Score Using Claims Data. Acad Pediatr 2022; 22:47-54. [PMID: 34256177 DOI: 10.1016/j.acap.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/25/2021] [Accepted: 07/03/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Pediatric asthma is a costly and complex disease with proven interventions to prevent exacerbations. Finding the patients at highest risk of exacerbations is paramount given limited resources. Insurance claims identify all outpatient, inpatient, emergency, pharmacy, and diagnostic services. The objective was to develop a risk score indicating the likelihood of asthma exacerbation within the next year based on prior utilization. METHODS A retrospective analysis of insurance claims for patients 2 to 18 years in a network in Massachusetts with 3 years of continuous enrollment in a commercial plan. Thirty-six potential predictors of exacerbation in the third year were assessed with a stepwise regression. Retained predictors were weighted relative to their contribution to asthma exacerbation risk and summed to create the Asthma Exacerbation Risk (AER) score. RESULTS In a cohort of 28,196 patients, there were 10 predictors associated with the outcome of having an asthma exacerbation in the next year that depend on age, meeting the Healthcare Effectiveness Data and Information Set persistent asthma criteria, fill patterns of asthma medications and oral steroids, counts of nonexacerbation outpatient visits, an exacerbation in the last 6 months, and whether spirometry was performed. The AER score is calculated monthly from a claims database to identify potential patients for an asthma home-visiting program. CONCLUSIONS The AER score assigns a risk of exacerbation within the next 12 months using claims data to identify patients in need of preventive services.
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Affiliation(s)
- Jonathan Hatoun
- Pediatric Physicians' Organization at Children's (J Hatoun, ET Correa, and L Vernacchio), Wellesley, Mass; Division of General Pediatrics, Boston Children's Hospital (J Hatoun and L Vernacchio), Boston, Mass; Department of Pediatrics, Harvard Medical School (J Hatoun, AJ MacGinnitie, JM Gaffin, and L Vernacchio), Boston, Mass.
| | - Emily Trudell Correa
- Pediatric Physicians' Organization at Children's (J Hatoun, ET Correa, and L Vernacchio), Wellesley, Mass
| | - Andrew J MacGinnitie
- Department of Pediatrics, Harvard Medical School (J Hatoun, AJ MacGinnitie, JM Gaffin, and L Vernacchio), Boston, Mass; Division of Immunology, Boston Children's Hospital (AJ MacGinnitie), Boston, Mass
| | - Jonathan M Gaffin
- Department of Pediatrics, Harvard Medical School (J Hatoun, AJ MacGinnitie, JM Gaffin, and L Vernacchio), Boston, Mass; Division of Pulmonary Medicine, Boston Children's Hospital (JM Gaffin), Boston, Mass
| | - Louis Vernacchio
- Pediatric Physicians' Organization at Children's (J Hatoun, ET Correa, and L Vernacchio), Wellesley, Mass; Division of General Pediatrics, Boston Children's Hospital (J Hatoun and L Vernacchio), Boston, Mass; Department of Pediatrics, Harvard Medical School (J Hatoun, AJ MacGinnitie, JM Gaffin, and L Vernacchio), Boston, Mass
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10
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Gloff MS, Robinson R, Correll LR, Lander H, Pyne S, Webber A. Preoperative optimization in the pediatric patient. Int Anesthesiol Clin 2022; 60:56-63. [PMID: 34711789 DOI: 10.1097/aia.0000000000000342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Marjorie S Gloff
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
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11
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Khanna A, Banoth B, Verma A, Bhalla K, Holla S, Yadav S. Comparative effectiveness of oral dexamethasone vs. oral prednisolone for acute exacerbation of asthma: A randomized control trial. J Family Med Prim Care 2022; 11:1395-1400. [PMID: 35516722 PMCID: PMC9067196 DOI: 10.4103/jfmpc.jfmpc_1210_21] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 10/12/2021] [Accepted: 12/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Acute exacerbation of asthma is a common condition leading to emergency visits. Prednisolone is a commonly prescribed drug in the standard management of acute exacerbation of asthma along with other drugs. This study was planned to see the efficacy of oral dexamethasone when compared with oral prednisolone in the management of acute exacerbation of asthma. Methods: A single-center pilot study in the form of randomized control trial was done by recruiting children aged 2–14 years diagnosed with acute asthma exacerbation with mild to moderate severity. A total of 88 patients received oral dexamethasone (0.3 mg/kg) in two doses 24 h apart, which was compared with 87 patients who received oral prednisolone (1 mg/kg) in two divided doses 12 h apart for 5 days. The patients were assessed at the time of admission (zero hour), at 4th hour, and on the 5th day by various parameters such as respiratory rate, use of accessory muscles, Pediatric Respiratory Assessment Measure (PRAM) score, peak expiratory flow rate (PEFR), 6-h admission stay, and rate of hospital admission. Results: Baseline demographic profile, clinical characteristics, comorbidities, indoor pollution, and use of Metered Dose Inhaler (MDI) among the two study groups were comparable. Six-hour emergency stay and rate of admission were significantly lower in the dexamethasone group (P < 0.05). Improvement in PRAM score, PEFR, use of accessory muscles, and respiratory rate was also better in dexamethasone group at the 4th hour and 5th day (P < 0.05). In addition, oral dexamethasone was shown to have less incidence of vomiting/gastritis than prednisolone (P < 0.05). Conclusion: Oral dexamethasone can be considered a reliable and better option as compared with prednisolone due to its faster action and minimal side effects.
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12
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Cai KJ, Su SQ, Wang YG, Zeng YM. Dexamethasone Versus Prednisone or Prednisolone for Acute Pediatric Asthma Exacerbations in the Emergency Department: A Meta-Analysis. Pediatr Emerg Care 2021; 37:e1139-e1144. [PMID: 32149991 DOI: 10.1097/pec.0000000000001926] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study evaluates the efficacy and tolerability of dexamethasone (DEX) as an alternative to prednisone/prednisolone (PRED) for the treatment of pediatric asthma exacerbations in emergency department (ED). METHODS Fixed-effects meta-analyses of selected endpoints were performed by using data taken from relevant studies identified by following a priori eligibility criteria after a comprehensive literature search in several electronic databases. RESULTS Data from 10 studies (3208 pediatric asthma patients [1616 DEX treated and 1592 PRED treated], 4.77 years [95% confidence interval, 3.80-5.56 years], 63% [57.76%-62.68%] males) were used. Risk of vomiting drug was significantly lower in DEX group than in PRED group (risk ratio, 0.29 [0.18-0.48]; P ˂ 0.00001). Emergency department stay between DEX and PRED treated patients was statistically different (0.16 [0.03-0.40] hours; P = 0.02) but may not be clinically meaningful. The number of β-agonist therapies received by DEX- and PRED-treated patients was similar. Treatments with both DEX and PRED were associated with improvement in asthma status assessment scores, and there was no significant difference between the groups. There were also no differences between the groups in hospitalization rate, ED revisit rate, and hospital admission rate after relapse. CONCLUSIONS Dexamethasone is a suitable alternative to PRED for the treatment of pediatric asthma exacerbation in ED.
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Affiliation(s)
| | | | | | - Yi-Ming Zeng
- Respiratory, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
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13
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Hemani SA, Glover B, Ball S, Rechler W, Wetzel M, Hames N, Jenkins E, Lantis P, Fitzpatrick A, Varghese S. Dexamethasone Versus Prednisone in Children Hospitalized for Acute Asthma Exacerbations. Hosp Pediatr 2021; 11:1263-1272. [PMID: 34610967 DOI: 10.1542/hpeds.2020-004788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Extensive literature supports using dexamethasone (DEX) in children presenting to the emergency department (ED) with mild-to-moderate asthma exacerbations; however, only limited studies have assessed this in hospitalized children. In this study, we evaluate the outcomes of DEX versus prednisone/prednisolone (PRED) use in children hospitalized for mild-to-moderate asthma exacerbations. METHODS This multisite retrospective cohort study included children between 3 and 21 years of age hospitalized to a tertiary care children's hospital system between January 1, 2013, and December 31, 2017, with a primary discharge diagnosis of acute asthma exacerbation or status asthmaticus. Primary study outcome was mean hospital length of stay (LOS). Secondary outcomes included PICU transfers during initial hospitalization and ED revisits and hospital readmissions within 10 days after discharge. Generalized linear models were used to model logged LOS as a function of steroid and demographic and clinical covariates. The analysis was stratified by initial steroid timing. RESULTS Of the 1410 children included, 981 received only DEX and 429 received only PRED. For children who started oral steroids after hospital arrival, DEX cohort had a significantly shorter adjusted mean hospital LOS (DEX 24.43 hours versus PRED 29.38 hours; P = .03). For children who started oral steroids before hospital arrival, LOS did not significantly differ (DEX 26.72 hours versus PRED 25.20 hours; P = .45). Rates of PICU transfers, ED revisits, and hospital readmissions were uncommon events. CONCLUSION Children hospitalized with mild-to-moderate asthma exacerbations have significantly shorter hospital LOS when starting DEX rather than PRED on admission.
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Affiliation(s)
- Sunita Ali Hemani
- Division of Hospital Medicine .,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Brianna Glover
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Samantha Ball
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Willi Rechler
- Rollins School of Public Health and Emory University School of Medicine, Atlanta, Georgia
| | - Martha Wetzel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Nicole Hames
- Division of Hospital Medicine.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Elan Jenkins
- Division of Hospital Medicine.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Patricia Lantis
- Division of General Pediatrics and Adolescent Medicine.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Anne Fitzpatrick
- Division of Pulmonology, Allergy/Immunology, Cystic Fibrosis and Sleep.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Sarah Varghese
- Division of Hospital Medicine.,Children's Healthcare of Atlanta, Atlanta, Georgia
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14
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Peterson R, Young KD. Dexamethasone Versus Prednisone for Pediatric Acute Asthma Exacerbations: Specialists' Practice Patterns. Pediatr Emerg Care 2021; 37:343-347. [PMID: 32149997 DOI: 10.1097/pec.0000000000002036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Dexamethasone has emerged as a viable alternative to prednisone in the treatment of pediatric acute asthma exacerbations, with the potential for improved compliance secondary to decreased frequency of dosing, improved taste, and decreased cost. The objective of this study is to identify whether providers are prescribing dexamethasone for pediatric acute asthma exacerbations. Secondary objectives are to describe variation in practice between different specialties and to identify the commonly used dosing and frequency for dexamethasone. METHODS We conducted a cross-sectional, descriptive study with an anonymous, web-based survey (surveymonkey.com). The survey population included all fellowship program directors listed on FRIEDA Online for pediatric emergency medicine, pediatric pulmonology, and allergy and immunology, and emergency medicine residency directors through the Council of Emergency Medicine Residency Directors listserv. Program directors were contacted via e-mail up to 5 times for 3 months. RESULTS Overall, 300 respondents (70% of the program directors) completed the survey. Response rates by specialty varied from 60% to 94%. One third of providers are using dexamethasone, whereas just more than half of providers (51%) are prescribing a 5-day prednisone course. The preferred maximum dose for dexamethasone is 10 mg (45%), with 82% using a dose of 0.6 mg/kg.Pediatric emergency medicine fellowship directors demonstrated a preference for dexamethasone (59%). Prednisone is favored by emergency medicine (56%), pediatric pulmonology (89%), and allergy and immunology (93%) program directors. CONCLUSIONS Although most pediatric emergency medicine academic physicians have transitioned to using dexamethasone to treat acute pediatric asthma exacerbations, other specialties continue to favor prednisone.
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Affiliation(s)
- Robert Peterson
- From the Department of Pediatrics, Division of Emergency Medicine and Emergency Department, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
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15
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Kim S, Kim K, Park J, Jun W. Curcuma longa L. Water Extract Improves Dexamethasone-Induced Sarcopenia by Modulating the Muscle-Related Gene and Oxidative Stress in Mice. Antioxidants (Basel) 2021; 10:1000. [PMID: 34201533 PMCID: PMC8300838 DOI: 10.3390/antiox10071000] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 12/25/2022] Open
Abstract
Dexamethasone (DEX) promotes proteolysis, which causes muscle atrophy. Muscle atrophy is connected to sarcopenia. We evaluated the effect of Curcuma longa L. water extract (CLW) on DEX-induced muscle atrophy. ICR mice were divided into three groups (eight mice per group) to investigate the capability of CLW in inhibiting muscle atrophy. The control group (Ex-CON) was administered distilled water (DW) by gavage and subjected to exercise; the muscle atrophy group (Ex-DEX) was administered DW by gavage, an injection of DEX (1 mg/kg body weight/day) intraperitoneally (IP), and subjected to exercise; and the treatment group (Ex-CLW) was administered CLW (1 g/kg body weight/day) by gavage, DEX IP injection, and subjected to exercise. Following the injection of DEX, the expression levels of myostatin, MuRF-1, and Atrogin-1 were increased. However, these expression levels were decreased in the Ex-CLW group, thereby leading to the conclusion that CLW inhibits muscle atrophy. ROS (that was overproduced by DEX) decreased antioxidant enzyme activity and increased malondialdehyde (MDA) levels, which led to muscle atrophy. When CLW was ingested, the antioxidant enzyme activities increased while the MDA levels decreased. These findings suggest that CLW could serve as a natural product for the prevention of muscle atrophy by modulating muscle atrophy-related genes and increasing antioxidant potential.
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Affiliation(s)
- Shintae Kim
- Division of Food and Nutrition, Chonnam National University, Gwangju 61187, Korea;
| | - Kyungmi Kim
- Department of Biofood Analysis, Korea Bio Polytechnic, Ganggyung 32946, Korea;
| | - Jeongjin Park
- Division of Food and Nutrition, Chonnam National University, Gwangju 61187, Korea;
- Research Institute for Human Ecology, Chonnam National University, Gwangju 61187, Korea
| | - Woojin Jun
- Division of Food and Nutrition, Chonnam National University, Gwangju 61187, Korea;
- Research Institute for Human Ecology, Chonnam National University, Gwangju 61187, Korea
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16
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Gileles-Hillel A, Guttman S, Breuer O, Reiter J, Leshem R, Shoseyov D, Kerem E, Cohen-Cymberknoh M. Betamethasone versus dexamethasone for inpatient preschool wheezing-A case-control study. Pediatr Pulmonol 2021; 56:875-882. [PMID: 33524229 DOI: 10.1002/ppul.25274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/20/2020] [Accepted: 01/11/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Wheezing is one of the most common reasons for the presentation of children to primary care or the emergency ward, before 7 years of age. Current guidelines recommend a short course of oral corticosteroids (OCS) for those children with a wheezing attack severe enough to require hospitalization. However, the optimal choice of therapy is controversial. We aimed to compare the efficacy of betamethasone to that of dexamethasone in achieving clinical response in preschool children requiring hospitalization for an acute wheezing attack. METHODS This was a retrospective study. Medical records of healthy children without significant comorbidities between 1 and 7 years of age (n = 234) admitted with a moderate-severity acute wheezing attack to two pediatric wards between 2014 and 2018 were included. All children were treated with either betamethasone or dexamethasone exclusively during the hospitalization. The primary outcome of interest was the length of hospital stay (LOS). RESULTS The demographic parameters and the clinical severity of wheezing episodes were similar in the two study groups, as was the LOS. However, the dexamethasone cumulative dose used during hospitalization was significantly larger than the betamethasone cumulative dose (3.76 (1.88-5.64) vs. 1.86 (1.24-3.1) mg/kg of prednisone-equivalent dose, p < .001). CONCLUSION In preschool children with acute wheezing requiring hospitalization, betamethasone achieved a similar clinical response when compared to dexamethasone, with a lower cumulative steroid dose. Further studies are needed to understand the additional benefits of betamethasone over other steroids or placebo.
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Affiliation(s)
- Alex Gileles-Hillel
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sharon Guttman
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Oded Breuer
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joel Reiter
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Regina Leshem
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Shoseyov
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eitan Kerem
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Malena Cohen-Cymberknoh
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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17
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Sharma S, Underdown MJ, Duffin TS, Triplett A, Hanes HC, Jones M, McCalla CD, Wood JK, Woods E, Eby Halvorson E. Systemic glucocorticoid at discharge after hospitalization for pediatric asthma: a prospective pilot study. J Asthma 2021; 59:775-779. [PMID: 33492180 DOI: 10.1080/02770903.2021.1879848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE: We examined asthma control in children hospitalized for status asthmaticus 7-10 days after discharge with or without an additional prescription for systemic corticosteroids. METHODS: This was a prospective observational study of patients aged 5-17 years with a documented history of asthma or β-agonist responsive wheezing admitted to the hospital for an acute asthma exacerbation. We compared patients who had any systemic corticosteroid prescribed at discharge with those who were not prescribed systemic corticosteroids at discharge. The primary outcomes were asthma control after discharge, as defined by the Asthma Control Test (ACT), and missed school days, which we modeled with multivariable linear and Poisson regression, respectively. RESULTS: A total of 56 patients were included in the study, 29 (52%) received dexamethasone inpatient and then were discharged without additional prescribed systemic corticosteroids. Those without a corticosteroid prescription at discharge were less likely to have received noninvasive ventilation (p = 0.02), pulmonology consultation (p = 0.02), and continuous albuterol (p = 0.01) during hospitalization. These patients also tended toward shorter length of stay (p = 0.07) compared to those receiving systemic corticosteroid prescription at discharge. In multivariable models, being discharged without systemic corticosteroid prescription was associated with poorer asthma control after discharge [beta (95% CI), -2.21 (-2.65 to -1.77)] and more missed school days [coefficient estimate (95% CI), 0.87 (0.07-1.68)]. CONCLUSIONS After hospitalization for an asthma exacerbation, patients not given systemic corticosteroids at discharge tended to have worse asthma control following discharge despite having less severe disease and requiring less aggressive inpatient management. Supplemental data for this article can be accessed at publisher's website.
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Affiliation(s)
- Srish Sharma
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mary Jane Underdown
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Taylor Stukes Duffin
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andrea Triplett
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Holly C Hanes
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael Jones
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Chad D McCalla
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Julie K Wood
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Elizabeth Woods
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, NC, USA
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18
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Lee MO, Sivasankar S, Pokrajac N, Smith C, Lumba‐Brown A. Emergency department treatment of asthma in children: A review. J Am Coll Emerg Physicians Open 2020; 1:1552-1561. [PMID: 33392563 PMCID: PMC7771822 DOI: 10.1002/emp2.12224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life-threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.
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Affiliation(s)
- Moon O. Lee
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Shyam Sivasankar
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Nicholas Pokrajac
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Cherrelle Smith
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Angela Lumba‐Brown
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
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19
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Comparative efficacy of glucocorticoid receptor agonists on Th2 cell function and attenuation by progesterone. BMC Immunol 2020; 21:54. [PMID: 33076829 PMCID: PMC7574173 DOI: 10.1186/s12865-020-00383-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/05/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Corticosteroids (CS)s suppress cytokine production and induce apoptosis of inflammatory cells. Prednisone and dexamethasone are oral CSs prescribed for treating asthma exacerbations. While prednisone is more commonly prescribed, dexamethasone is long acting and a more potent glucocorticoid receptor (GR) agonist. It can be administered as a one or two dose regime, unlike the five to seven days required for prednisone, a feature that increases compliance. We compared the relative ability of these two oral CSs to suppress type 2 inflammation. Since progesterone has affinity for the GR and women are more likely to relapse following an asthma exacerbation, we assessed its influence on CS action. RESULTS Dexamethasone suppressed the level of IL-5 and IL-13 mRNA within Th2 cells with ~ 10-fold higher potency than prednisolone (the active form of prednisone). Dexamethasone induced a higher proportion of apoptotic and dying cells than prednisolone, at all concentrations examined. Addition of progesterone reduced the capacity of both CS to drive cell death, though dexamethasone maintained significantly more killing activity. Progesterone blunted dexamethasone-induction of FKBP5 mRNA, indicating that the mechanism of action was by interference of the CS:GR complex. CONCLUSIONS Dexamethasone is both more potent and effective than prednisolone in suppressing type 2 cytokine levels and mediating apoptosis. Progesterone attenuated these anti-inflammatory effects, indicating its potential influence on CS responses in vivo. Collectively, our data suggest that when oral CS is required, dexamethasone may be better able to control type 2 inflammation, eliminate Th2 cells and ultimately lead to improved long-term outcomes. Further research in asthmatics is needed.
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20
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Buddala PK, Chandrasekaran V, Harichandrakumar KT. A 3-day course of 1 mg/kg versus 2 mg/kg bodyweight prednisolone for 1- to 5-year-old children with acute moderate exacerbation of asthma: a randomized double-blind noninferiority trial. Paediatr Child Health 2020; 26:e189-e193. [PMID: 34136056 DOI: 10.1093/pch/pxaa082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background Even though the guidelines on the management of preschool asthma recommend early use of corticosteroids for acute moderate-to-severe exacerbations, considerable variation exists with regard to type and dose of steroids. Objectives To compare the clinical outcomes and side effect profile between 1 mg/kg/day and 2 mg/kg/day of oral prednisolone when administered for 3 days in preschool children with acute moderate asthma exacerbations. Study Design and Setting Randomized double-blind noninferiority trial was done in the paediatric emergency of a teaching hospital. Patients Interventions and Outcomes A total of 128 children aged 1 to 5 years who presented to the paediatric emergency with acute moderate exacerbation of asthma were enrolled. They were randomized into two groups. One group received 1 mg/kg/day and the other 2 mg/kg/day of oral prednisolone for 3 days. Severity of asthma exacerbation was measured by Pediatric Respiratory Assessment Measure (PRAM) score. The PRAM scores, wheeze recurrence, and side effect profile were compared and analyzed between the two groups. Results The difference in the PRAM scores at 1, 2, 3, and 4 hours after intervention between the two groups was statistically insignificant. Need for escalation of therapy, salbutamol nebulization, time for resolution of symptoms, and recurrence of wheeze were similar between the two groups. Vomiting was significantly less frequent in low-dose group with a relative risk of 0.19 to 0.99 compared to high-dose prednisolone. Conclusion Prednisolone at a dose of 1 mg/kg/day was not inferior to 2 mg/kg/day in terms of clinical improvement and recurrence of wheeze within 1 week and has less frequent vomiting compared to higher dose.
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Affiliation(s)
- Pavan Kumar Buddala
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Venkatesh Chandrasekaran
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - K T Harichandrakumar
- Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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21
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Rodriguez-Martinez CE, Sossa-Briceño MP, Castro-Rodriguez JA. Dexamethasone or prednisolone for asthma exacerbations in children: A cost-effectiveness analysis. Pediatr Pulmonol 2020; 55:1617-1623. [PMID: 32394644 DOI: 10.1002/ppul.24817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/02/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Although a short course (ie, 3 to 5 days) of orally administered prednisolone is a common and widely accepted practice among clinicians for administering systemic corticosteroids in pediatric acute asthma, oral dexamethasone for 1 to 2 days is an attractive alternative to prednisolone due to its better palatability and compliance. However, a cost-effectiveness analysis regarding the use of dexamethasone compared to prednisolone is not sufficient, especially in lower- and middle-income countries. The objective of this study was to analyze the cost-effectiveness of prednisolone vs oral dexamethasone for treating pediatric asthma exacerbations. METHODS Using a decision-analysis model, we analyzed the cost-effectiveness of prednisolone vs oral dexamethasone for treating acute pediatric asthma. Effectiveness parameters were derived from a systematic review of the published literature. Data for costs were acquired from hospital accounts and from an official national database, the national manual of drug prices in Colombia. The study was carried out from a Colombian third-party payer perspective. The principal outcome of the model was the avoidance of hospitalization. RESULTS The base-case analysis showed that compared to dexamethasone, administering prednisolone was associated with lower overall treatment costs (US$93.97 vs US$104.91 mean cost per patient) without a significant difference in the probability of hospitalization avoided (.9108 vs .9108). CONCLUSIONS The present study shows that in Colombia, a middle-income country, compared with oral dexamethasone, the use of prednisolone for treating acute pediatric asthma is cost-effective, yielding a similar probability of hospitalization at lesser overall costs.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Jose A Castro-Rodriguez
- Department of Pediatric Pulmonology, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
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22
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Navanandan N, Moran E, Smith H, Hoch H, Mistry RD. Primary care provider preferences for glucocorticoid management of acute asthma exacerbations in children. J Asthma 2020; 58:547-553. [PMID: 31877252 DOI: 10.1080/02770903.2019.1709869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Primary care providers (PCP) frequently care for children with acute asthma exacerbations in the outpatient setting. The objective of this study is to evaluate PCP preferences and perceptions regarding oral glucocorticoids prescribed from both outpatient primary care and ED settings for the treatment of children with acute asthma exacerbations. METHODS PCPs belonging to the Colorado Chapter of the American Academy of Pediatrics were surveyed between February and May 2019. Survey items were generated by a multidisciplinary team and underwent content and criteria validation and pilot testing. Survey items evaluated PCP preferred oral glucocorticoid and dosing regimen for children with acute asthma exacerbations, provider- and patient-level factors contributing to glucocorticoid preferences, and perception of glucocorticoid regimens in terms of treatment failure, resolution of symptoms and adherence. RESULTS A total of 109 of 600 (18.2%) PCPs responded. Equal proportions of PCPs reported preferring oral prednisone/prednisolone (50.5%) and oral dexamethasone (49.5%) for children with acute asthma exacerbations. Forty-four percent of PCPs reported no preference in type of glucocorticoid utilized by surrounding emergency departments (EDs). However, for children receiving dexamethasone in the ED but with persistent symptoms on PCP follow-up, 50.5% of PCPs would switch patients to prednisone/prednisolone. PCPs did not perceive more treatment failure or rapid resolution of symptoms with dexamethasone but reported better adherence with dexamethasone. CONCLUSION There is variability in PCP glucocorticoid management of pediatric acute asthma exacerbations. There is a need for further investigations to evaluate for differences in clinical outcomes based on PCP glucocorticoid treatment choices.
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Affiliation(s)
- Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Elizabeth Moran
- Baylor College of Medicine, Section of Emergency Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Hana Smith
- General Academic Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Heather Hoch
- Children's Hospital Colorado, University of Colorado School of Medicine, Breathing Institute, Aurora, Colorado, USA
| | - Rakesh D Mistry
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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23
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Endogenous Glucocorticoid Response to Single-Dose Dexamethasone for Croup in Children: A Pharmacodynamic Study. Pediatr Emerg Care 2020; 36:50-56. [PMID: 28398936 DOI: 10.1097/pec.0000000000001142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Dexamethasone is associated with adrenal insufficiency in adults and children with chronic disease. This association has not been studied after single-dose oral dexamethasone, the standard of care for children with croup. We hypothesized that single-dose oral dexamethasone in children with croup is associated with a transient decrease in endogenous glucocorticoids. METHODS We conducted a prospective, 2-arm, pharmacodynamic study of single-dose oral dexamethasone 0.6 mg/kg (maximum, 12 mg) in children older than 2 years with croup compared with controls (children with febrile upper respiratory tract infections who did not receive dexamethasone). Primary outcome was urinary 6β-hydroxycortisol-cortisol ratio. RESULTS Twenty-seven children were analyzed (22 with croup and 5 with upper respiratory tract infections). Median 6β-hydroxycortisol-cortisol ratios before dexamethasone, the following morning, and on days 1, 3, and 7 were 2.8, 2.2, 2.0, 2.8, and 2.6, respectively. Among controls, the median 6β-hydroxycortisol-cortisol ratios at the same time intervals was 1.9, 1.5, 1.8, 2.5, and 1.7, respectively. There were no significant differences in the change from time 0 between groups at any time point. There were no serious adverse events or infectious complications. CONCLUSIONS Single-dose oral dexamethasone is not associated with decreased endogenous corticosteroid levels in children with croup. Future studies should use criterion standard tests to rule out suppression of the hypothalamic-pituitary-adrenal axis and be powered sufficiently to identify adverse clinical outcomes.
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24
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Wei J, Lu Y, Han F, Zhang J, Liu L, Chen Q. Oral Dexamethasone vs. Oral Prednisone for Children With Acute Asthma Exacerbations: A Systematic Review and Meta-Analysis. Front Pediatr 2019; 7:503. [PMID: 31921718 PMCID: PMC6923200 DOI: 10.3389/fped.2019.00503] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 11/21/2019] [Indexed: 11/13/2022] Open
Abstract
Background: This systematic review and meta-analysis was conducted to compare relapse rates and adverse effects with oral dexamethasone vs. oral prednisone for acute asthma exacerbations in pediatric patients. Methods: A computerized literature search of PubMed, Embase, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google scholar databases was carried out till 1st August 2019. Six Randomized controlled trials (RCTs) and 1 quasi-RCT were included. 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 1.46, 95%CI 0.69-3.7, P = 0.32; I 2 = 0%) and 10-15 days of follow up (RR 1.16, 95%CI 0.80-1.68, P = 0.44; I 2 = 0%). Pooled analysis found no significant difference in relapse rates with 1-day (RR 1.15, 95%CI 0.68-1.95, P = 0.60; I 2 = 0%) and 2-day dosage of dexamethasone (RR 1.25, 95%CI 0.82-1.92, P = 0.30; I 2 = 0%) compared to prednisone. Hospital readmission rates after initial discharge were not significantly different between the two drugs (RR 1.49, 95%CI 0.56-4.01, P = 0.43; I 2 = 0%). Frequency of vomiting at ED (RR 0.21, 95%CI 0.05-0.96, P = 0.04; I 2 = 50%) and at home (RR 0.42, 95%CI 0.25-0.69, P = 0.0007; I 2 = 0%) was significantly higher with prednisone as compared to dexamethasone. 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.
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Affiliation(s)
- Jienan Wei
- Department of Pediatrics, Shengli Oilfield Central Hospital, Dongying, China
| | - Yan Lu
- Department of Pediatrics, Shengli Oilfield Central Hospital, Dongying, China
| | - Fang Han
- Department of Hematology, Shengli Oilfield Central Hospital, Dongying, China
| | - Jing Zhang
- Department of Pediatrics, Shengli Oilfield Central Hospital, Dongying, China
| | - Lan Liu
- Department of Pediatrics, Shengli Oilfield Central Hospital, Dongying, China
| | - Qingqing Chen
- Department of Pediatrics, Shengli Oilfield Central Hospital, Dongying, China
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25
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Cotter JM, Tyler A, Reese J, Ziniel S, Federico MJ, Anderson Iii WC, Kupfer O, Szefler SJ, Kerby G, Hoch HE. Steroid variability in pediatric inpatient asthmatics: survey on provider preferences of dexamethasone versus prednisone. J Asthma 2019; 57:942-948. [PMID: 31113252 DOI: 10.1080/02770903.2019.1622713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Our hospital's pediatric Emergency Department (ED) began using dexamethasone for treating asthma exacerbations after ED studies showed non-inferiority of dexamethasone compared to prednisone. However, providers have not reached consensus on optimal inpatient steroid regimen. This study evaluates provider preference for inpatient steroid treatment.Methods: A survey was distributed to providers who care for inpatient pediatric asthmatics. Respondents answered questions about steroid choice and timing. Data were summarized as percentages; bivariate comparisons were analyzed with Pearson's chi-squared test.Results: Ninety-two providers completed the survey (60% response rate). When patients received dexamethasone in the ED, subsequent inpatient management was variable: 44% continued dexamethasone, 14% switched to prednisone, 2% said no additional steroids, and 40% said it depended on the scenario. Hospitalists were more likely to continue dexamethasone than pulmonologists (61% and 15%, respectively; p < .001). Factors that influenced providers to switch to prednisone in the inpatient setting included severity of exacerbation (73%) and asthma history (47%). Fifty-one percent felt uncomfortable using dexamethasone because of "minimal data to support [its] use inpatient." In case-based questions, 28% selected dexamethasone dosing intervals outside the recommended range. Thirteen percent reported experiencing errors in clinical practice.Conclusions: Use of dexamethasone in the ED for asthma exacerbations has led to uncertainty in inpatient steroid prescribing practices. Providers often revert to prednisone, especially in severe asthma exacerbations, possibly due to experience with prednisone and limited research on dexamethasone in the inpatient setting. Further research comparing the effectiveness of dexamethasone to prednisone in inpatient asthmatic children with various severities of illness is needed.
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Affiliation(s)
- Jillian M Cotter
- Section of Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Tyler
- Section of Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jennifer Reese
- Section of Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sonja Ziniel
- Section of Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Monica J Federico
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - William C Anderson Iii
- Allergy and Immunology Section, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Oren Kupfer
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Gwendolyn Kerby
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Heather E Hoch
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
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26
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Bohannon K, Machen R, Ragsdale C, Padilla-Tolentino E, Cervenka P. Dexamethasone Associated With Significantly Shorter Length of Hospital Stay Compared With a Prednisolone-Based Regimen in Pediatric Patients With Mild to Moderate Acute Asthma Exacerbations. Clin Pediatr (Phila) 2019; 58:521-527. [PMID: 30854887 DOI: 10.1177/0009922819832091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A retrospective chart review was done to evaluate the efficacy of a course of dexamethasone for pediatric patients hospitalized with a mild to moderate acute asthma exacerbation compared with a prednisone-based regimen. Patients were identified based on International Classification of Diseases (ICD-9 and ICD-10) discharge diagnosis codes for asthma and cross-referenced with pharmacy dispense reports during the study period of June 2011 to January 2016. Baseline characteristics were similar among the 2 groups. The median length of hospital stay in the dexamethasone and prednisolone groups were 1.31 and 1.75 days, respectively, with a hazard ratio of 2.5 (95% confidence interval - 2.1-3.1), P < .001. After accounting for significant confounding variables, the difference in length of stay remained significantly longer in the prednisolone group with a hazard ratio of 1.8 (95% confidence interval = 1.4-2.3), P < .001. A course of dexamethasone is associated with a significantly shorter length of stay for mild to moderate asthma exacerbations compared with a prednisone-based regimen.
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Affiliation(s)
- Kristin Bohannon
- 1 Dell Children's Medical Center of Central Texas, Austin, TX, USA
| | - Ronda Machen
- 1 Dell Children's Medical Center of Central Texas, Austin, TX, USA
| | - Carolyn Ragsdale
- 1 Dell Children's Medical Center of Central Texas, Austin, TX, USA
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27
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Volk AS, Marton SA, Richardson BS, Rauda L, Schwarzwald HL, Naik NM. Oral Dexamethasone to Control Wheezing in Children at an Outpatient Clinic. Clin Pediatr (Phila) 2019; 58:151-158. [PMID: 30378445 DOI: 10.1177/0009922818809466] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Asthma, a chronic childhood disease, has resulted in increased emergency department (ED) visits with high costs. Many asthma ED visits are nonemergent and could be treated in outpatient clinics. Literature has concluded that a 2-day course of oral dexamethasone has comparable outcomes to a 5-day course of prednisone in the ED and hospital setting. A retrospective chart review was performed on children requiring in-house treatment with a corticosteroid (dexamethasone n = 23, prednisone n = 40) for acute asthma exacerbations at an ambulatory medical home. The rates of hospital admissions, ED visits, and symptom follow-up were similar between the 2 groups ( P > .05). The cost for a course of dexamethasone was US$1.28 versus US$16.20 for prednisolone. The average cost for an asthma exacerbation office visit was US$79.89 compared with US$3113.28 for an ED visit. A 2-day course of oral dexamethasone appears to be a promising clinical and cost-effective treatment for acute asthma exacerbations at the primary care level.
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Affiliation(s)
| | | | | | - Luis Rauda
- 3 Texas Children's Health Plan, Bellaire, TX, USA
| | | | - Neel M Naik
- 2 Baylor College of Medicine, Houston, TX, USA
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28
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Tyler A, Cotter JM, Moss A, Topoz I, Dempsey A, Reese J, Szefler S, Hoch H. Outcomes for Pediatric Asthmatic Inpatients After Implementation of an Emergency Department Dexamethasone Treatment Protocol. Hosp Pediatr 2019; 9:92-99. [PMID: 30670462 DOI: 10.1542/hpeds.2018-0099] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Evidence supports using dexamethasone for mild-to-moderate asthma exacerbations in the emergency department, but the effectiveness of dexamethasone versus prednisone for asthmatic patients who are hospitalized is unclear. Our aim was to compare outcomes for inpatients before and after our emergency department's adoption of dexamethasone for the treatment of acute asthma exacerbations. METHODS In this single-center retrospective cohort study, we employed interrupted time series analyses to control for secular trends while evaluating our outcomes of length of stay, total inflation-adjusted hospital charges, and ICU transfer rates for patients admitted with asthma. RESULTS Data were analyzed over 36 months (January 2014-April 2017) and included 1015 subjects (606 in the preprotocol change [pre-PC] group and 409 in the postprotocol change [post-PC] group). In the pre-PC group, prednisone only was used in 96% of subjects. In the post-PC group, prednisone only was used in 7% of subjects, dexamethasone in 65% of subjects, and a combination of the 2 steroids in 28% of subjects. Controlling for other variables in the interrupted time series model, we found no significant immediate differences between the pre-PC and post-PC periods for the outcomes of length of stay (P = .68), total charges (P = .66), and ICU transfers (P = .98). The rate of ICU transfers was stable pre-PC and increased by 10% (95% confidence interval: 2%-19%) per month (odds ratio = 1.10; 95% confidence interval: 1.02-1.19; P = .02) in the post-PC period. CONCLUSIONS After dexamethasone replaced prednisone as the most commonly prescribed steroid type for inpatients with asthma at our institution, we found no immediate changes in outcomes for asthmatic patients who were hospitalized but an upward trend in ICU transfers.
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Affiliation(s)
- Amy Tyler
- Children's Hospital Colorado, Aurora, Colorado; .,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Jillian M Cotter
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Irina Topoz
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Amanda Dempsey
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Jennifer Reese
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Stanley Szefler
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Heather Hoch
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
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29
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Elkharwili DA, Ibrahim OM, Elazab GA, Elrifaey SM. Two regimens of dexamethasone versus prednisolone for acute exacerbations in asthmatic Egyptian children. Eur J Hosp Pharm 2018; 27:151-156. [PMID: 32419935 DOI: 10.1136/ejhpharm-2018-001707] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 10/04/2018] [Accepted: 10/09/2018] [Indexed: 11/04/2022] Open
Abstract
Introduction Asthma is one of the most prevalent chronic respiratory diseases, which often leads to an emergency department visit. Prednisolone is the most commonly used corticosteroid in treatment of asthma exacerbation. Oral dexamethasone demonstrates bioavailability similar to that of oral prednisolone but has a longer half-life. Objective To evaluate in adouble-blind, randomised clinical trial the efficacy of different doses of dexamethasone versus prednisolone in controlling asthma exacerbations in children. Methods We recruited 60 patients with asthma exacerbation, aged 2-11 years. Participants were randomly divided into three groups (20 patients each). Group I received a single dose of oral dexamethasone 0.3 mg/kg (maximum 12 mg), group II received 0.6 mg/kg/day of oral dexamethasone for 2 days (maximum 16 mg/day) and group III received 1.5 mg/kg/day oral prednisolone for 5 days (maximum 60 mg/day). Our primary outcomes were changes in Paediatric Respiratory Assessment Measure (PRAM), eosinophilic count and serum immunoglobulin E on day 5. Secondary endpoints were reporting any adverse effects and relapse rate during the 5 days. After 30 days, the Asthma Therapy Assessment Questionnaire (ATAQ) was given to the parents of the recruited patients. Results Among the three study groups, there was a highly statistically significant difference in IgE level, saturated oxygen, peak expiratory flow, forced expiratory volume in 1 s/forced vital capacity, PRAM and Modified Pulmonary Index Score; however, the eosinophilic count was significantly lower within the same group. Vomiting, gastrointestinal tract cramps, ATAQ and relapse rate showed a non-statistically significant difference. Conclusion Single-dose dexamethasone was at least as effective as 5-day course of prednisolone in controlling asthma, while dexamethasone for 2 days was non-inferior to 5 days of prednisolone in children with asthma exacerbation.
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Affiliation(s)
- Dalia A Elkharwili
- Clinical Pharmacy Department, Faculty of Pharmacy, Tanta University, Tanta, Egypt
| | - Osama M Ibrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Tanta University, Tanta, Egypt
| | - Gamal A Elazab
- Clinical Pharmacy Department, Faculty of Pharmacy, Tanta University, Tanta, Egypt
| | - Shaymaa M Elrifaey
- Pediatrics Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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30
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Kirkland SW, Vandermeer B, Campbell S, Villa-Roel C, Newton A, Ducharme FM, Rowe BH. Evaluating the effectiveness of systemic corticosteroids to mitigate relapse in children assessed and treated for acute asthma: A network meta-analysis. J Asthma 2018; 56:522-533. [PMID: 29693459 DOI: 10.1080/02770903.2018.1467444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this systematic review was to explore the effectiveness of various systemic corticosteroid (SCS) regimens to mitigate relapse in children with asthma discharged from an acute care setting. DATA SOURCES Medline, EMBASE, Global Health, International Pharmaceutical Abstracts, EMB ALL, CINAHL, SCOPUS, Proquest Dissertations and Theses Global, and LILACS were searched using controlled vocabulary and key words. Additional citations were searched via clinical trial registries, Google Scholar, bibliographies, a SCOPUS forward search of a sentinel paper, and hand searching conference abstracts. STUDY SELECTION No limitations based on language, publication status, or year of publication were applied. Two independent reviewers searched to identify randomized controlled trials comparing the effectiveness of SCS regimens to prevent relapse in children following treatment for acute asthma. RESULTS Fifteen studies were included. In 3 studies comparing SCS to placebo, asthma relapse was significantly reduced (RR = 0.10; 95% CI: 0.01, 0.77; I2 = 0%). A network analysis identified a significant reduction in relapse in children treated with intramuscular corticosteroids (OR = 0.038; 95% CrI: 0.001, 0.397), short-course oral prednisone (OR = 0.054; 95% CrI: 0.002, 0.451), and oral dexamethasone (OR = 0.071; 95% CrI: 0.002, 0.733) compared to placebo. CONCLUSION This review found evidence that SCS reduces relapse in children following treatment for acute asthma, albeit based on a limited number of studies. Additional studies are required to assess the differential effect of SCS doses and treatment duration to prevent relapse in children following discharge for acute asthma.
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Affiliation(s)
- Scott W Kirkland
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada
| | - Ben Vandermeer
- b Department of Pediatrics, Alberta Research Centre for Health Evidence , University of Alberta, Edmonton Clinic Health Academy , Edmonton , AB , Canada
| | - Sandy Campbell
- c J.W. Scott Health Sciences Library , University of Alberta , Walter C. Mackenzie Health Sciences Centre, Edmonton , AB , Canada
| | - Cristina Villa-Roel
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada
| | - Amanda Newton
- d Department of Pediatrics , University of Alberta , Edmonton , AB , Canada
| | - Francine M Ducharme
- e Departments of Pediatrics and of Social and Preventive Medicine , University of Montreal , Montreal , Quebec , Canada
| | - Brian H Rowe
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada.,f School of Public Health, University of Alberta , Edmonton Clinic Health Academy , Edmonton , AB , Canada
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31
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Randomized trial of dexamethasone versus prednisone for children with acute asthma exacerbations: why? J Pediatr 2018; 197:316-317. [PMID: 29550227 DOI: 10.1016/j.jpeds.2018.01.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/22/2018] [Indexed: 11/21/2022]
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32
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Mintegi S, Paniagua N, Pijoan JI, Gorostizaga Z, Gonzalez M, Benito J. Dexamethasone for Pediatric Asthma Exacerbations: A Quality Improvement Intervention. Am J Med Qual 2018; 33:671. [PMID: 29561171 DOI: 10.1177/1062860618765676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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33
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Batabyal RA, O’Connell K. Improving Management of Severe Asthma: BiPAP and Beyond. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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34
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Pilot Clinical Trial of High-Flow Oxygen Therapy in Children with Asthma in the Emergency Service. J Pediatr 2018; 194:204-210.e3. [PMID: 29331328 DOI: 10.1016/j.jpeds.2017.10.075] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/23/2017] [Accepted: 10/25/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To assess the efficacy of high-flow nasal cannula (HFNC) oxygen therapy and safety in children with asthma and moderate respiratory failure in the emergency department (ED). STUDY DESIGN This was a prospective randomized pilot trial of children (aged 1-14 years) presenting to a tertiary academic pediatric ED with moderate-to-severe asthma exacerbations between September 2012 and December 2015. Patients with a pulmonary score (PS) ≥6 or oxygen saturation <94% with a face mask despite initial treatment (salbutamol/ipratropium bromide and corticosteroids) were randomized to HFNC or to conventional oxygen therapy. Pharmacologic treatment was at the discretion of attending physicians. The primary outcome was a decrease in PS ≥2 in the first 2 hours. Secondary outcomes included disposition, length of stay, and need for additional therapies. RESULTS We randomly allocated 62 children to receive either HFNC (n = 30) or standard oxygen therapy (n = 32). Baseline patient characteristics were similar in the 2 groups. At 2 hours after the start of therapy, PS had decreased by ≥2 points in 16 patients in the HFNC group (53%) compared with 9 controls (28%) (P = .01). Between-group differences in disposition, length of stay, and need for additional therapies were not significant. No side effects were reported. CONCLUSION HFNC appears to be superior to conventional oxygen therapy for reducing respiratory distress within the first 2 hours of treatment in children with moderate-to-severe asthma exacerbation refractory to first-line treatment. Further studies are needed to demonstrate its overall efficacy in the management of asthma and respiratory failure in the ED. TRIAL REGISTRATION EudraCT: 2012-001771-36.
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35
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Mathew JL, Walia MK. Oral Dexamethasone versus Oral Prednisolone in Acute Asthma: A New Randomized Controlled Trial and Updated Meta-analysis. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1250-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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36
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Abstract
Systemic corticosteroids are recommended in clinical practice guidelines for the treatment of acute asthma exacerbation based on evidence demonstrating reduced hospitalizations and improved outcomes after administration in the emergency department. Although prednisone and related oral preparations have been recommended previously, researchers have assessed dexamethasone as an alternative based on its longer biologic half-life and improved palatability. Systematic reviews of multiple small trials and 2 larger trials have found no difference in revisits to the emergency department compared to prednisone for dexamethasone given either as an intramuscular injection or orally. Studies of oral administration have found reduced emesis for dexamethasone compared to prednisone both in the emergency department and for a second oral dose, typically given 24 to 48 hours later. Studies assessing a single dose of dexamethasone have found equivalent improvement at follow-up but with some evidence of increased symptoms and increased need for additional corticosteroids compared to multiple doses of prednisone. Future research could further assess dexamethasone dose, formulation, and frequency and measure other related adverse effects such as behavior change. Consideration of baseline differences within the heterogeneous population of children requiring acute care for asthma may also guide the design of an optimal dexamethasone regimen.
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37
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Paniagua N, Lopez R, Muñoz N, Tames M, Mojica E, Arana-Arri E, Mintegi S, Benito J. Randomized Trial of Dexamethasone Versus Prednisone for Children with Acute Asthma Exacerbations. J Pediatr 2017; 191:190-196.e1. [PMID: 29173304 DOI: 10.1016/j.jpeds.2017.08.030] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/18/2017] [Accepted: 08/14/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine whether 2 doses of dexamethasone is as effective as 5 days of prednisolone/prednisone therapy in improving symptoms and quality of life of children with asthma exacerbations admitted to the emergency department (ED). STUDY DESIGN We conducted a randomized, noninferiority trial including patients aged 1-14 years who presented to the ED with acute asthma to compare the efficacy of 2 doses of dexamethasone (0.6 mg/kg/dose, experimental treatment) vs a 5-day course of prednisolone/prednisone (1.5 mg/kg/d, followed by 1 mg/kg/d on days 2-5, conventional treatment). Two follow-up telephone interviews were completed at 7 and 15 days. The primary outcome measures were the percentage of patients with asthma symptoms and quality of life at day 7. Secondary outcomes were unscheduled returns, admissions, adherence, and vomiting. RESULTS During the study period, 710 children who met the inclusion criteria were invited to participate and 590 agreed. Primary outcome data were available in 557 patients. At day 7, experimental and conventional groups did not show differences related to persistence of symptoms (56.6%, 95% CI 50.6-62.6 vs 58.3%, 95% CI 52.3-64.2, respectively), quality of life score (80.0 vs 77.7, not significant [ns]), admission rate (23.9% vs 21.7%, ns), unscheduled ED return visits (4.6% vs 3.3%, ns), and vomiting (2.1% vs 4.4%, ns). Adherence was greater in the dexamethasone group (99.3% vs 96.0%, P < .05). CONCLUSION Two doses of dexamethasone may be an effective alternative to a 5-day course of prednisone/prednisolone for asthma exacerbations, as measured by persistence of symptoms and quality of life at day 7. CLINICAL TRIAL REGISTRATION clinicaltrialsregister.eu: 2013-003145-42.
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Affiliation(s)
- Natalia Paniagua
- Pediatric Emergency Department, Cruces University Hospital, BioCruces Health Research Institute. Bilbao, Basque Country, Spain.
| | - Rebeca Lopez
- Pediatric Emergency Department, Cruces University Hospital, BioCruces Health Research Institute. Bilbao, Basque Country, Spain
| | - Natalia Muñoz
- Pediatric Emergency Department, Cruces University Hospital, BioCruces Health Research Institute. Bilbao, Basque Country, Spain
| | - Miriam Tames
- Pediatric Emergency Department, Cruces University Hospital, BioCruces Health Research Institute. Bilbao, Basque Country, Spain
| | - Elisa Mojica
- Pediatric Emergency Department, Cruces University Hospital, BioCruces Health Research Institute. Bilbao, Basque Country, Spain
| | - Eunate Arana-Arri
- Epidemiology Unit, Cruces University Hospital, BioCruces Health Research Institute. Bilbao, Basque Country, Spain
| | - Santiago Mintegi
- Pediatric Emergency Department, Cruces University Hospital, BioCruces Health Research Institute. Bilbao, Basque Country, Spain
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, BioCruces Health Research Institute. Bilbao, Basque Country, Spain
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38
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Seghezzo S, Arnold DH, Gay JC, Moore PE, Johnson DP. Dexamethasone for inpatient childhood asthma exacerbations is as effective as short-acting corticosteroid treatment. Ann Allergy Asthma Immunol 2017; 120:94-95. [PMID: 29162317 DOI: 10.1016/j.anai.2017.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/22/2017] [Accepted: 10/01/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Sara Seghezzo
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Donald H Arnold
- Center for Asthma Research, and Division of Emergency Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James C Gay
- Division of General Pediatrics, Department of Pediatrics, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Paul E Moore
- Center for Asthma Research, and Division of Allergy Immunology and Pulmonology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David P Johnson
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee
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39
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McCallister A, So TY, Stewart J. Evaluation of the Efficacy of a Onetime Injectable Dexamethasone Administered Orally in the Pediatric Emergency Department for Asthma Exacerbation. J Pediatr Pharmacol Ther 2017; 22:326-331. [PMID: 29042832 DOI: 10.5863/1551-6776-22.5.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study assessed the efficacy of injectable dexamethasone administered orally in pediatric patients who presented to the emergency department with asthma exacerbation. METHODS This was a retrospective study of patients 0 to 18 years of age who presented to and who were directly discharged from the emergency department at Moses H. Cone Memorial Hospital between September 1, 2012, and September 30, 2015, for the diagnosis of asthma or asthma exacerbation. Patients had to receive a onetime dose of injectable dexamethasone orally prior to discharge. Patients were followed for a 30-day period to identify the number of asthma relapses. RESULTS Ninety-nine patients were included in this study. The average weight-based dose ± SD of dexamethasone was 0.35 ± 0.18 mg/kg (range, 0.08-0.62 mg/kg) and the actual dose ± SD was 10.58 ± 1.92 mg (range, 5-16 mg). Over a 30-day period, 6 patients (6%) had one repeated emergency department visit, 6 patients (6%) were admitted to the hospital, and 3 patients (3%) presented to an outpatient clinic for asthma-related symptoms. CONCLUSIONS Injectable dexamethasone administered orally may be an efficacious treatment for asthma exacerbation in pediatric patients. A randomized control trial comparing injectable dexamethasone administered orally to other dexamethasone formulations/routes of administration should be performed to adequately assess the bioequivalence and effectiveness of the former formulation.
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Affiliation(s)
- Ashley McCallister
- Department of Pharmacy (AM, T-YS), Moses H. Cone Memorial Hospital, Greensboro, North Carolina, University of North Carolina at Chapel Hill Eshelman School of Pharmacy (JS), Chapel Hill, North Carolina
| | - Tsz-Yin So
- Department of Pharmacy (AM, T-YS), Moses H. Cone Memorial Hospital, Greensboro, North Carolina, University of North Carolina at Chapel Hill Eshelman School of Pharmacy (JS), Chapel Hill, North Carolina
| | - Josh Stewart
- Department of Pharmacy (AM, T-YS), Moses H. Cone Memorial Hospital, Greensboro, North Carolina, University of North Carolina at Chapel Hill Eshelman School of Pharmacy (JS), Chapel Hill, North Carolina
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Abstract
In adults, respiratory disorders are the second most frequent diagnoses treated in emergency department observation units (EDOUs) and account for the most frequent indication for placement of pediatric patients into an EDOU. With appropriate patient selection, chronic obstructive pulmonary disease exacerbations, and community-acquired pneumonia can be managed in the EDOU. EDOU management results in equivalent or better outcomes than inpatient care with decreased length of stay, increased patient satisfaction, lower cost and in some studies decreased mortality. Evidence-based protocols are important to ensure appropriate patients are placed in the EDOU, standardize best practice interventions, and guide disposition decisions.
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Bergene EH, Rø TB, Steinsbekk A. Strategies parents use to give children oral medicine: a qualitative study of online discussion forums. Scand J Prim Health Care 2017; 35:221-228. [PMID: 28581890 PMCID: PMC5499324 DOI: 10.1080/02813432.2017.1333308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIM The aim of this study was to describe strategies parents use to give oral medicine to children. METHODS We conducted an Internet-based qualitative study of posts from online forums where parents discussed how to give children oral medicine. The posts were analyzed using systematic text condensation. The investigators coded and developed groups iteratively, ending up with a consensus on final themes. RESULTS We included 4581 posts. Parents utilized three main strategies to give oral medicine to children: (1) Open administration give medicine to the child knowingly by changing the palatability, actively involve the child in play or use persuasion; (2) Hidden administration give medicine to the child unknowingly by camouflaging it in food, while sleeping or distracted by another activity; (3) Forced administration force children to take medicine with the use of restraint. Parents expressed three perspectives towards using force: Finding it unproblematic, using force despite not liking it or refusing to use force. No single strategy was described as the obvious first choice, and the strategies were not used in any particular order. Parents who gave up getting their child to ingest the medicine reported to contact the prescriber for a different medication, or stopped the treatment completely. CONCLUSIONS The three strategies are a robust and precise way to categorize techniques used by parents to give children oral medicine. We suggest that health professionals use the strategies to talk to parents and children about administration of oral medicines.
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Affiliation(s)
- Elin Høien Bergene
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Central Norway Hospital Pharmacy Trust, Trondheim, Norway
- CONTACT Elin Høien Bergene Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), N-7491 Trondheim, Norway
| | - Torstein Baade Rø
- Department of Pediatrics, St. Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Aslak Steinsbekk
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Bravo-Soto GA, Harismendy C, Rojas P, Silva R, von Borries P. Is dexamethasone as effective as other corticosteroids for acute asthma exacerbation in children? Medwave 2017; 17:e6931. [PMID: 28430773 DOI: 10.5867/medwave.2017.6931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 02/28/2017] [Indexed: 11/27/2022] Open
Abstract
Dexamethasone has been proposed as an alternative in the treatment of acute asthma exacerbation in children. It allows shortening the duration of treatment, reducing costs and adverse effects. However, it is not clear whether its efficacy is similar to the traditional steroid regimen. To answer this question, we searched in Epistemonikos database, which is maintained by screening multiple information sources. We identified six systematic reviews including 10 randomized trials. We extracted data, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We concluded dexamethasone has probably fewer adverse effects than others corticosteroids, and might be equally effective in reducing hospitalizations and revisits.
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Affiliation(s)
- Gonzalo A Bravo-Soto
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile. . Address: Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago Centro, Chile
| | - Constanza Harismendy
- Proyecto Epistemonikos, Santiago, Chile; Departamento de Medicina Familiar, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pamela Rojas
- Proyecto Epistemonikos, Santiago, Chile; Departamento de Medicina Familiar, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rodrigo Silva
- Proyecto Epistemonikos, Santiago, Chile; Departamento de Medicina Familiar, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pamela von Borries
- Proyecto Epistemonikos, Santiago, Chile; Departamento de Medicina Familiar, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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One and Done: Steroids for Adult Asthma: Answers to the November 2016 Journal Club Questions. Ann Emerg Med 2017; 69:503-512. [PMID: 28335918 DOI: 10.1016/j.annemergmed.2016.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Brown K, Iqbal S, Sun SL, Fritzeen J, Chamberlain J, Mullan PC. Improving timeliness for acute asthma care for paediatric ED patients using a nurse driven intervention: an interrupted time series analysis. BMJ QUALITY IMPROVEMENT REPORTS 2016; 5:bmjquality_uu216506.w5621. [PMID: 28090325 PMCID: PMC5223673 DOI: 10.1136/bmjquality.u216506.w5621] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 09/22/2016] [Indexed: 11/03/2022]
Abstract
Asthma is the most common chronic paediatric disease treated in the emergency department (ED). Rapid corticosteroid administration is associated with improved outcomes, but our busy ED setting has made it challenging to achieve this goal. Our primary aim was to decrease the time to corticosteroid administration in a large, academic paediatric ED. We conducted an interrupted time series analysis for moderate to severe asthma exacerbations of one to 18 year old patients. A multidisciplinary team designed the intervention of a bedside nurse initiated administration of oral dexamethasone, to replace the prior system of a physician initiated order for oral prednisone. Our baseline and intervention periods were 12 month intervals. Our primary process measure was the time to corticosteroid administration. Other process measures included ED length of stay, admission rate, and rate of emesis. The balance measures included rate of return visits to the ED or clinic within five days, as well as the proportion of discharged patients who were admitted within five days. No special cause variation occurred in the baseline period. The mean time to corticosteroid administration decreased significantly, from 98 minutes in the baseline period to 59 minutes in the intervention period (p < 0.01), and showed special cause variation improvement within two months after the intervention using statistical process control methodology. We sustained the improvement and demonstrated a stable process. The intervention period had a significantly lower admission rate (p<0.01) and emesis rate (p<0.01), with no unforeseen harm to patients found with any of our balance measures. In summary, the introduction of a nurse initiated, standardized protocol for corticosteroid therapy for asthma exacerbations in a paediatric ED was associated with decreased time to corticosteroid administration, admission rates, and post-corticosteroid emesis.
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An Overview of Pediatric Asthma. PHYSICIAN ASSISTANT CLINICS 2016. [DOI: 10.1016/j.cpha.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Weinberger M. Rebuttal From Dr Weinberger. Chest 2016; 150:494. [DOI: 10.1016/j.chest.2016.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 11/25/2022] Open
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Schuh S, Sweeney J, Freedman SB, Coates AL, Johnson DW, Thompson G, Gravel J, Ducharme FM, Zemek R, Plint AC, Beer D, Klassen T, Curtis S, Black K, Nicksy D, Willan AR. Magnesium nebulization utilization in management of pediatric asthma (MagNUM PA) trial: study protocol for a randomized controlled trial. Trials 2016; 17:261. [PMID: 27220675 PMCID: PMC4879727 DOI: 10.1186/s13063-015-1151-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 12/30/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Up to 30 % of children with acute asthma are refractory to initial therapy, and 84 % of this subpopulation needs hospitalization. Finding safe, noninvasive, and effective strategies to treat this high-risk group would substantially decrease hospitalizations, healthcare costs, and the psycho-social burden of the disease. Whereas intravenous magnesium (Mg) is effective in severe refractory asthma, its use is sporadic due to safety concerns, with the main treatment goal being to prevent intensive care unit admission. In contrast, nebulized Mg is noninvasive, allows higher pulmonary drug concentrations, and has a much higher safety potential due to the lower rate of systemic delivery. Previous studies of inhaled Mg show disparate results due to the use of unknown/inefficient delivery methods and other methodological flaws. METHODS/DESIGN The study is a randomized double-blind controlled trial in seven Canadian pediatric Emergency Departments (two-center pilot 2011 to 2014, Canada-wide November 2014 to December 2017). The trial will include 816 otherwise healthy children who are 2 to 17 years old, having had at least one previous wheezing episode, have received systemic corticosteroids, and have a Pediatric Respiratory Assessment Measure (PRAM) ≥ 5 points after three salbutamol and ipratropium treatments for a current acute asthma exacerbation. Eligible consenting children will receive three experimental treatments of nebulized salbutamol with either 600 mg of Mg sulfate or placebo 20 min apart, using an Aeroneb Go nebulizer, which has been shown to maximize pulmonary delivery while maintaining safety. The primary outcome is hospitalization within 24 h of the start of the experimental therapy for persistent respiratory distress or supplemental oxygen. Secondary outcomes include all-cause hospitalization within 24 h, PRAM, vital signs, number of bronchodilator treatments by 240 min, and the association between the difference in the primary outcome between the groups, age, gender, baseline PRAM, atopy, and "viral induced wheeze" phenotype (Fig. 1). DISCUSSION If effective, inhaled Mg may represent an effective strategy to minimize morbidity in pediatric refractory acute asthma. Unlike previous works, this trial targets nonresponders to optimized initial therapy who are the most likely to benefit from inhaled Mg. Future dissemination of results will include knowledge translation, incorporation into a Cochrane Review, presentation at scientific meetings, and a peer-reviewed publication. TRIAL REGISTRATION NCTO1429415 , registered 2 September 2011.
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Affiliation(s)
- Suzanne Schuh
- />Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Judy Sweeney
- />SickKids Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8 Canada
| | - Stephen B. Freedman
- />Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
| | - Allan L. Coates
- />SickKids Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - David W. Johnson
- />Departments of Paediatrics, Pharmacology and Physiology, Alberta Children’s Hospital Research Institute, Faculty of Medicine, University of Calgary, C4,643, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
| | - Graham Thompson
- />Division of Pediatric Emergency Medicine, Alberta Children’s Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
| | - Jocelyn Gravel
- />Division of Paediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 3175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
| | - Francine M. Ducharme
- />Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
| | - Roger Zemek
- />Division of Pediatric Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Amy C. Plint
- />Division of Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Darcy Beer
- />Divsion of Pediatric Emergency Medicine, The Children’s Hospital of Winnipeg, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3J 1R9 Canada
| | - Terry Klassen
- />Children’s Hospital Research Institute of Manitoba (formerly Manitoba Institute of Child Health), Academic Faculty of Medicine, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Department of Pediatrics and Child Health, University of Manitoba, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Child Health Program, Winnipeg Health Region MICH, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
| | - Sarah Curtis
- />Division of Paediatric Emergency Medicine, Stollery Children’s Hospital, University of Alberta, 8440 112 Street Northwest, Edmonton, AB T6G 2B7 Canada
| | - Karen Black
- />Division of Pediatric Emergency Medicine, University of British Columbia, BC Children’s Hospital, 4480 Oak St, Vancouver, BC V6H 3N1 Canada
| | - Darcy Nicksy
- />SickKids Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8 Canada
| | - Andrew R. Willan
- />Child Health Evaluative Sciences, SickKids Research Institute, Dalla Lana School of Public Health, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - on behalf of Pediatric Emergency Research Canada Group
- />Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- />Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
- />Departments of Paediatrics, Pharmacology and Physiology, Alberta Children’s Hospital Research Institute, Faculty of Medicine, University of Calgary, C4,643, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
- />Division of Pediatric Emergency Medicine, Alberta Children’s Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
- />Division of Paediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 3175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
- />Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
- />Division of Pediatric Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
- />Division of Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
- />Divsion of Pediatric Emergency Medicine, The Children’s Hospital of Winnipeg, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3J 1R9 Canada
- />Children’s Hospital Research Institute of Manitoba (formerly Manitoba Institute of Child Health), Academic Faculty of Medicine, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Department of Pediatrics and Child Health, University of Manitoba, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Child Health Program, Winnipeg Health Region MICH, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Division of Paediatric Emergency Medicine, Stollery Children’s Hospital, University of Alberta, 8440 112 Street Northwest, Edmonton, AB T6G 2B7 Canada
- />Division of Pediatric Emergency Medicine, University of British Columbia, BC Children’s Hospital, 4480 Oak St, Vancouver, BC V6H 3N1 Canada
- />SickKids Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- />Child Health Evaluative Sciences, SickKids Research Institute, Dalla Lana School of Public Health, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- />SickKids Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8 Canada
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Abstract
BACKGROUND Asthma is a common long-term breathing condition that affects approximately 300 million people worldwide. People with asthma may experience short-term worsening of their asthma symptoms; these episodes are often known as 'exacerbations', 'flare-ups', 'attacks' or 'acute asthma'. Oral steroids, which have a potent anti-inflammatory effect, are recommended for all but the most mild asthma exacerbations; they should be initiated promptly. The most often prescribed oral steroids are prednisolone and dexamethasone, but current guidelines on dosing vary between countries, and often among different guideline producers within the same country. Despite their proven efficacy, use of steroids needs to be balanced against their potential to cause important adverse events. Evidence is somewhat limited regarding optimal dosing of oral steroids for asthma exacerbations to maximise recovery while minimising potential side effects, which is the topic of this review. OBJECTIVES To assess the efficacy and safety of any dose or duration of oral steroids versus any other dose or duration of oral steroids for adults and children with an asthma exacerbation. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov (www.ClinicalTrials.gov), the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/) and reference lists of all primary studies and review articles. This search was up to date as of April 2016. SELECTION CRITERIA We included parallel randomised controlled trials (RCTs), irrespective of blinding or duration, that evaluated one dose or duration of oral steroid versus any other dose or duration, for management of asthma exacerbations. We included studies involving both adults and children with asthma of any severity, in which investigators analysed adults and children separately. We allowed any other co-intervention in the management of an asthma exacerbation, provided it was not part of the randomised treatment. We included studies reported as full text, those published as abstract only and unpublished data. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results for included trials, extracted numerical data and assessed risk of bias; all data were cross-checked for accuracy. We resolved disagreements by discussion with the third review author or with an external advisor.We analysed dichotomous data as odds ratios (ORs) or risk differences (RDs) using study participants as the unit of analysis; we analysed continuous data as mean differences (MDs). We used a random-effects model, and we carried out a fixed-effect analysis if we detected statistical heterogeneity. We rated all outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system and presented results in 'Summary of findings' tables. MAIN RESULTS We included 18 studies that randomised a total of 2438 participants - both adults and children - and performed comparisons of interest. Included studies assessed higher versus lower doses of prednisolone (n = 4); longer versus shorter courses of prednisolone (n = 3) or dexamethasone (n = 1); tapered versus non-tapered courses of prednisolone (n = 4); and prednisolone versus dexamethasone (n = 6). Follow-up duration ranged from seven days to six months. The smallest study randomised just 15 participants, and the largest 638 (median 93). The varied interventions and outcomes reported limited the number of meaningful meta-analyses that we could perform.For two of our primary outcomes - hospital admission and serious adverse events - events were too infrequent to permit conclusions about the superiority of one treatment over the other, or their equivalence. Researchers in the included studies reported asthma symptoms in different ways and rarely used validated scales, again limiting our conclusions. Secondary outcome meta-analysis was similarly hampered by heterogeneity among interventions and outcome measures used. Overall, we found no convincing evidence of differences in outcomes between a higher dose or longer course and a lower dose or shorter course of prednisolone or dexamethasone, or between prednisolone and dexamethasone.Included studies were generally of reasonable methodological quality. Review authors assessed most outcomes in the review as having low or very low quality, meaning we are not confident in the effect estimates. The predominant reason for downgrading was imprecision, but indirectness and risk of bias also reduced our confidence in some estimates. AUTHORS' CONCLUSIONS Evidence is not strong enough to reveal whether shorter or lower-dose regimens are generally less effective than longer or higher-dose regimens, or indeed that the latter are associated with more adverse events. Any changes recommended for current practice should be supported by data from larger, well-designed trials. Varied study design and outcome measures limited the number of meta-analyses that we could perform. Greater emphasis on palatability and on whether some regimens might be easier to adhere to than others could better inform clinical decisions for individual patients.
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Affiliation(s)
- Rebecca Normansell
- St George's, University of LondonPopulation Health Research InstituteLondonUKSW17 0RE
| | - Kayleigh M Kew
- St George's, University of LondonPopulation Health Research InstituteLondonUKSW17 0RE
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Rehrer MW, Liu B, Rodriguez M, Lam J, Alter HJ. A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma. Ann Emerg Med 2016; 68:608-613. [PMID: 27117874 DOI: 10.1016/j.annemergmed.2016.03.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 02/24/2016] [Accepted: 03/03/2016] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE 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. 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. Outcomes including relapse were assessed by a follow-up telephone interview at 2 weeks. RESULTS One hundred seventy-three dexamethasone and 203 prednisone subjects completed the study regimen and telephone follow-up. The dexamethasone group by a small margin surpassed the preset 8% difference between groups for noninferiority in relapse rates within 14 days (12.1% versus 9.8%; difference 2.3%; 95% confidence interval -4.1% to 8.6%). Subjects in the 2 groups had similar rates of hospitalization for their relapse visit (dexamethasone 3.4% versus prednisone 2.9%; difference 0.5%; 95% confidence interval -4.1% to 3.1%). Adverse effect rates were generally the same in the 2 groups. CONCLUSION 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.
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Affiliation(s)
- Matthew W Rehrer
- Department of Emergency Medicine, Kaiser Permanente, Oakland, CA.
| | - Bella Liu
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Marcela Rodriguez
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Joseph Lam
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Harrison J Alter
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
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Aljebab F, Choonara I, Conroy S. Systematic review of the toxicity of short-course oral corticosteroids in children. Arch Dis Child 2016; 101:365-70. [PMID: 26768830 PMCID: PMC4819633 DOI: 10.1136/archdischild-2015-309522] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 12/02/2015] [Accepted: 12/03/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Short-course oral corticosteroids are commonly used in children but are known to be associated with adverse drug reactions (ADRs). This review aimed to identify the most common and serious ADRs and to determine their relative risk levels. METHODS A literature search of EMBASE, MEDLINE, International Pharmaceutical Abstracts, CINAHL, Cochrane Library and PubMed was performed with no language restrictions to identify studies in which oral corticosteroids were administered to patients aged 28 days to 18 years of age for up to and including 14 days of treatment. Each database was searched from their earliest dates to December 2013. All studies providing clear information on ADRs were included. RESULTS Thirty-eight studies including 22 randomised controlled trials (RCTs) met the inclusion criteria. The studies involved a total of 3200 children in whom 850 ADRs were reported. The three most frequent ADRs were vomiting, behavioural changes and sleep disturbance, with respective incidence rates of 5.4%, 4.7% and 4.3% of patients assessed for these ADRs. Infection was one of the most serious ADRs; one child died after contracting varicella zoster. When measured, 144 of 369 patients showed increased blood pressure; 21 of 75 patients showed weight gain; and biochemical hypothalamic-pituitary-adrenal axis suppression was detected in 43 of 53 patients. CONCLUSIONS Vomiting, behavioural changes and sleep disturbance were the most frequent ADRs seen when short-course oral corticosteroids were given to children. Increased susceptibility to infection was the most serious ADR. TRIAL REGISTRATION NUMBER CRD42014008774. By PROSPERO International prospective register of systematic reviews.
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Affiliation(s)
- Fahad Aljebab
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
| | - Imti Choonara
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
| | - Sharon Conroy
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
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