Adherence of pediatric asthma patients with oral corticosteroid prescriptions following pediatric emergency department visit or hospitalization

Emergency department discharge practices for children with acute wheeze and asthma: a survey of discharge practice and review of safety netting instructions in the UK and Ireland

OBJECTIVE

Recovery from acute wheeze and asthma attacks should be supported with safety netting, including treatment advice. We evaluated emergency department (ED) discharge practices for acute childhood wheeze/asthma attacks to describe variation in safety netting and recovery bronchodilator dosing.

DESIGN

Two-phase study between June 2020 and September 2021, comprising (1) Departmental discharge practice survey, and (2) Analysis of written discharge instructions for caregivers.

SETTING

Secondary and tertiary EDs in rural and urban settings, from Paediatric Emergency Research in the UK and Ireland (PERUKI).

MAIN OUTCOME MEASURES

Describe practice and variation in discharge advice, treatment recommendations and safety netting provision.

RESULTS

Of 66/71 (93%) participating sites, 62/66 (93.9%) reported providing written safety netting information. 52/66 (78.8%) 'nearly always' assessed inhaler/spacer technique; routine medication review (21/66; 31.8%) and adherence (16/66; 21.4%) were less frequent. In phase II, 61/66 (92.4%) submitted their discharge documents; 50/66 (81.9%) included bronchodilator plans. 11/66 (18.0%) provided Personalised Asthma Action Plans as sole discharge information. 45/50 (90%) provided 'fixed' bronchodilator dosing regimes; dose tapering was common (38/50; 76.0%). Median starting dose was 10 puffs 4 hourly (27/50, 54.0%); median duration was 4 days (29/50, 58.0%). 13/61 (21.3%) did not provide bronchodilator advice for acute deterioration; where provided, 42/48 (87.5%) recommended 10 puffs immediately. Subsequent dosages varied considerably. Common red flags included inability to speak (52/61, 85.2%), inhalers not lasting 4 hours (51/61, 83.6%) and respiratory distress (49/61, 80.3%).

CONCLUSIONS

There is variation in bronchodilator dosing and safety netting content for recovery following acute wheeze and asthma attacks. This reflects a lack of evidence, affirming need for further multicentre studies regarding bronchodilator recovery strategies and optimal safety netting advice.

Impact of a discharge prescription for dexamethasone on outcomes of children treated in the emergency department for acute asthma exacerbations

OBJECTIVE

To evaluate dexamethasone prescribing practices, patient adherence, and outcomes by dosing regimen in children with acute asthma discharged from the emergency department (ED).

STUDY DESIGN

Prospective study of children 2-18 years treated with dexamethasone for acute asthma prior to discharge from an urban, tertiary care ED between 2018 and 2022. Demographics, clinical characteristics, ED treatment, and discharge prescriptions were collected via chart review. The exposure was discharge prescription (additional dose) versus no discharge prescription for dexamethasone. The primary outcome was treatment failure, defined as return ED visit, unplanned primary care visit, and/or ongoing bronchodilator use. Secondary outcomes included medication adherence, symptom persistence, quality-of-life, and school/work absenteeism. Outcomes were assessed by telephone 7-10 days after discharge.

RESULTS

564 subjects were enrolled; 338 caregivers (60%) completed follow-up. Children were a median age 7 years, 30% Black or African American, 49% Hispanic, and 79% had public insurance. A discharge prescription for dexamethasone was written for 482 (86%) children and was significantly associated with exacerbation severity, number of combined albuterol/ipratropium treatments, and longer length of stay. There was no difference in treatment failure between the discharge prescription and no discharge prescription groups (RR 0.87; 0.67, 1.12), including after adjusting for potential confounders; there was no difference between groups in secondary outcomes.

CONCLUSIONS

Prescription for an additional dexamethasone dose was not associated with reduced treatment failure or improved outcomes for children with acute asthma discharged from the ED. Single, ED-dose of dexamethasone prior to discharge may be sufficient for children with mild to moderate asthma exacerbations.

A survey of United States dermatologists' knowledge, attitudes, and practices with intramuscular triamcinolone

Since the 1970s, intramuscular triamcinolone (IMT) has been available as an option for systemic corticosteroid use in dermatology. Although shown to be safe and effective in early studies, this method of systemic corticosteroid delivery fell out of favor in the 1980s in many United States residency programs. To identify factors associated with US dermatologists' preferences for and use of IMT we surveyed a random sample of US board-certified dermatologists to assess knowledge, attitudes, and practices regarding IMT in dermatologists' daily clinical practice. A total of 844 out of 2000 dermatologists completed the survey (42.2%). Only 55.0% reported feeling comfortable using IMT for steroid-responsive dermatoses, while 90.4% felt comfortable using oral corticosteroids for steroid-responsive dermatoses. Most participants (59.2%) did not prefer IMT over oral corticosteroids when both were indicated. One third (33.3%) of the participants reported that none of the faculty during their residency advocated using IMT. Receiving education on IMT indications (OR = 1.96 [95% CI: 1.46-2.63]) and encouragement to use IMT (OR = 4.29 [95% CI: 3.01-6.11]) during residency were positively associated with use of IMT at least once a month in current practice. Current knowledge, attitudes, and practices surrounding IMT vary amongst practicing dermatologists. Modifiable factors such as training could improve comfort with use of this short-term systemic steroid treatment modality.

Dexamethasone Versus Prednisone in Children Hospitalized With Asthma Exacerbation

OBJECTIVES

Dexamethasone is increasingly used for the management of children hospitalized with asthma in place of prednisone, yet data regarding the effectiveness of dexamethasone in children with asthma exacerbation severe enough to require hospitalization are limited. Our objective is to compare the effectiveness of dexamethasone versus prednisone in children hospitalized with an asthma exacerbation on 30-day reutilization.

METHODS

We conducted a retrospective cohort study at an urban, quaternary children's hospital of children aged 4 to 17 years, hospitalized from January 1, 2014 to December 31, 2017, with a primary discharge diagnosis of asthma. A covariate-balanced propensity score was derived to account for physician discretion in steroid selection. A generalized linear model, including inverse probability treatment weighting, was used to detect differences in 30-day return utilization (unplanned readmission or emergency department visit) between children whose first dose of corticosteroid was dexamethasone versus prednisone.

RESULTS

Inclusion criteria were met by 1161 patients, of which 510 (44%) first received dexamethasone versus 651 (56%) who first received prednisone. The total cohort had a mean age of 8.5 years (SD 3.4). The covariate-balanced cohort had no significant differences in demographic characteristics or illness severity between groups. The dexamethasone group had a return utilization of 3.9% (20 of 510) versus 2.2% (14 of 651) for children treated with prednisone. The propensity score-adjusted analysis revealed the steroid treatment was not found to significantly affect the 30-day reutilization (adjusted odds ratio [aOR] 1.61; 95%CI 0.80-3.31).

CONCLUSIONS

The initial steroid choice (dexamethasone versus prednisone) was not associated with 30-day reutilization after hospitalization for an asthma exacerbation.

Long-term Effectiveness of a Peer-Led Asthma Self-management Program on Asthma Outcomes in Adolescents Living in Urban Areas: A Randomized Clinical Trial

Importance

Long-term effectiveness of a peer-led asthma self-management program in improving asthma outcomes in adolescents living in urban areas has not been established.

Objective

To determine the long-term effects of a peer-led program on asthma control, quality of life, and asthma management among predominantly racial and ethnic minority adolescents living in urban areas.

Design, Setting, and Participants

A parallel-group, randomized clinical trial was conducted in 2015 to 2019 in 3 metropolitan cities in the US: Buffalo, New York; Baltimore, Maryland; and Memphis, Tennessee. Adolescents aged 12 to 17 years old with persistent asthma were recruited mainly through clinical practices and schools. Participants were followed-up for 15 months after the intervention. Double-blinding was achieved for baseline. Data analysis was performed from June 2019 to June 2020.

Interventions

The intervention group received a peer-led asthma self-management program; the control group received the identical program led by adult health care professionals. Peer leaders made follow-up contacts every other month for 12 months.

Main Outcomes and Measures

The primary outcome was quality of life measured by the Pediatric Asthma Quality of Life Questionnaire, which consists of 3 subscales that measure symptoms (10 items), activity limitations (5 items), and emotional functioning (8 items) in the past 2 weeks. Each item was measured on a 7-point scale, with higher mean scores indicating better quality of life. Secondary measures included the Asthma Control Questionnaire and an asthma self-management index capturing steps to prevent and manage symptoms, self-efficacy, and lung function.

Results

Of 395 eligible adolescents, 35 refused, 38 did not show or were lost to contact, and 2 withdrew before randomization; 320 adolescents participated (mean [SD] age, 14.3 [1.71] years), including 168 boys (52.5%), 251 Black or African American adolescents (78.4%), and 232 adolescents (72.5%) with public health insurance. Of 320 enrolled, 303 were included in the longitudinal analysis. Response rates were 80% or higher at all time points. The peer-led group had greater improvement in outcomes than the adult-led group, with adjusted mean differences (AMDs) between baseline and 15 months of 0.75 vs 0.37 for quality of life (between-group AMD, 0.38; 95% CI, 0.07 to 0.63) and -0.59 vs -0.31 for asthma control (between-group AMD, -0.28; 95% CI, -0.51 to -0.01). Outcomes were not affected by bimonthly contact doses.

Conclusions and Relevance

In this randomized clinical trial, a peer-led asthma self-management education was more effective than an adult-led program in improving asthma outcomes, with the improvements sustained for up to 15 months. These findings suggest that a peer-led asthma self-management program should be considered in addressing the disproportionate asthma burden in racial and ethnic minority adolescents living in urban communities.

Trial Registration

ClinicalTrials.gov Identifier: NCT02293499.

Dexamethasone Versus Prednisone in Children Hospitalized for Acute Asthma Exacerbations

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.

Corticosteroid choice and clinical outcomes for asthma exacerbations in the primary care setting

OBJECTIVE

To evaluate clinical outcomes in young children with acute asthma exacerbations treated with prednisone/prednisolone versus dexamethasone in the primary care setting.

METHODS

Retrospective cohort study of children ages 3-9 years with a primary care clinic visit for asthma and an associated oral corticosteroid (OCS) prescription fill in the Colorado All Payers Claim Database between 2/2013-3/2019. This was a secondary analysis of a dataset extracted to analyze risk of future development of asthma in younger children. The primary outcome was subsequent ED visit or hospital admission for asthma within 2-14 days after the index clinic visit. Demographics and asthma health services characteristics were assessed. Multivariable logistic regression was used to estimate the association between type of OCS prescription filled within 1 day of the index clinic visit and the primary outcome.

RESULTS

There were 3236 index clinic visits for asthma for 1918 children during the study period. Sixty-two percent were male and 66% were 3-4 years old. Prednisone/prednisolone accounted for 84% of OCS prescriptions fills within 1 day of the index clinic visit. One percent visited the ED and 1% required hospital admission within 2-14 days. In multivariate analysis, there was no statistical association between type of OCS prescribed and the primary outcome (OR 0.82; 95% CI: 0.37-1.8).

CONCLUSIONS

There are no differences in clinical outcomes by type of OCS prescribed for acute asthma exacerbations in the primary care setting. Due to better adherence and side effect profile, primary care providers may consider to use dexamethasone as the preferred OCS.

Clinical factors associated with the use of dexamethasone for asthma in the pediatric emergency department

BACKGROUND

Dexamethasone is efficacious for the treatment of pediatric asthma exacerbations but is not specifically recommended by current national guidelines.

OBJECTIVES

To describe the factors associated with prescribed dexamethasone in a pediatric emergency department (PED) and upon patient discharge.

METHODS

Retrospective chart review of patients aged 2 to 18 years discharged home from a PED with a diagnostic code for asthma (J45x). Descriptive statistics are reported and binary logistic regression with generalized estimating equations was used to examine the demographic and clinical factors associated with dexamethasone use in the PED and upon discharge.

RESULTS

594 children contributed 690 visits for asthma. Two-thirds of patients received prednisone in the PED (n = 430; 62%). Among 260 children who received dexamethasone, 76% (n = 198) were prescribed a second dose for post-discharge administration. Multivariable models showed that patients triaged as most urgent had a 50% reduction in the odds of receiving dexamethasone in the PED (OR = 0.5; 95% CI = 0.28-0.87). Patients seen by a pediatrician (OR 4.2; 95%CI 2.1-8.3) and those triaged as urgent (OR 2.9; 95% CI = 1.8-7.8) were more likely to receive a single dose of dexamethasone.

CONCLUSIONS

Dexamethasone is less commonly used in the PED for asthmatic patients triaged as most urgent. Triage acuity and level of training were associated with single-dose treatment of asthma in those receiving dexamethasone. Further studies are needed to clarify the use of dexamethasone across the spectrum of asthma severity.

Dexamethasone or prednisolone for asthma exacerbations in children: A cost-effectiveness analysis

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.

Primary care provider preferences for glucocorticoid management of acute asthma exacerbations in children

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.

Treatment Adherence in Adolescents with Asthma

The burden of asthma is particularly notable in adolescents, and is associated with higher rates of prevalence and mortality compared with younger children. One factor contributing to inadequate asthma control in adolescents is poor treatment adherence, with many pediatric studies reporting mean adherence rates of 50% or lower. Identifying the reasons for poor disease control and adherence is essential in order to help improve patient quality of life. In this review, we explore the driving factors behind non-adherence in adolescents with asthma, consider their consequences and suggest possible solutions to ensure better disease control. We examine the impact of appropriate inhaler choice and good inhaler technique on adherence, as well as discuss the importance of selecting the right medication, including the possible role of as-needed inhaled corticosteroids/long-acting β₂-agonists vs short-acting β₂-agonists, for improving outcomes in patients with mild asthma and poor adherence. Effective patient/healthcare practitioner communication also has a significant role to engage and motivate adolescents to take their medication regularly.

Oral Dexamethasone vs. Oral Prednisone for Children With Acute Asthma Exacerbations: A Systematic Review and Meta-Analysis

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.

Factors Associated With Pickup of Pediatric Discharge Prescriptions

BACKGROUND AND OBJECTIVES

Lack of medication pickup is associated with worse clinical outcomes for select patients. Identification of risk factors for not picking up discharge medications or approaches to this problem have received little study. We sought to identify factors associated with medication pickup rates after hospitalization at a tertiary care children's hospital.

METHODS

We conducted a retrospective cohort study of 178 discharges from a children's hospital. We contacted pharmacies that received electronic prescriptions to ascertain whether patients and families picked up medications. The principal outcome was pickup of all medications within 48 hours of discharge. Covariates included demographic data, insurance type, discharge diagnosis, home zip code median income, medication number and/or class, and pharmacy type (on-site versus off-site). We performed a multivariable logistic regression analysis.

RESULTS

Overall, 142 of 178 (80%) discharges involved medication pickup. Patient age and sex, diagnosis, discharge day, primary language, and hospitalization length had no statistically significant association with medication pickup. On the multivariable analysis, a higher home zip code median income (P = .045; highest versus lowest groups) had a statistically significant association with increased medication pickup. Private insurance had a statistically significant association with higher pickup rate on the univariable analysis (P = .01) but not on the multivariable analysis, which included zip code income (P = .072). On-site pharmacy use (P = .048) and prescription of an anti-infective (P = .003) had statistically significant associations with higher medication pickup rates.

CONCLUSIONS

Certain factors are associated with rates of medication pickup after discharge. Use of an on-site hospital pharmacy may represent a strategy to improve medication pickup rates in children who are hospitalized.

Oral Dexamethasone to Control Wheezing in Children at an Outpatient Clinic

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.

Dexamethasone versus prednisone for children receiving asthma treatment in the paediatric inpatient population: protocol for a feasibility randomised controlled trial

INTRODUCTION

Asthma exacerbations are a leading cause of paediatric hospitalisations. Corticosteroids are key in the treatment of asthma exacerbations. Most current corticosteroids treatment regimens for children admitted with asthma exacerbation consist of a 5-day course of prednisone or prednisolone. However, these medications are associated with poor taste and significant vomiting, resulting in poor compliance with the treatment course. While some centres already use a short course of dexamethasone for treating children hospitalised with asthma, there is no evidence to support this practice in the inpatient population.

METHODS AND ANALYSIS

This single-site, pragmatic, feasibility randomised controlled trial will determine the feasibility of a non-inferiority trial, comparing two treatment regimens for children admitted to the hospital and receiving asthma treatment. Children 18 months to 17 years presenting to a Canadian tertiary care centre will be randomised to receive either a short course of dexamethasone or a longer course of prednisone/prednisolone once admitted to the inpatient units. The primary clinical outcome for this feasibility study will be readmission to hospital or repeat emergency department visits, or unplanned visits to primary healthcare providers for asthma symptoms within 4 weeks of hospital discharge. Feasibility outcomes will include recruitment and allocation success, compliance with study procedures, retention rate, and safety and tolerability of study medications. We plan on recruiting 51 children, and between-group comparisons of the clinical outcome will be conducted to gain insights on probable effect sizes.

ETHICS AND DISSEMINATION

Research Ethics Board approval has been obtained for this study. The results of this study will inform a multisite trial comparing prednisone/prednisolone to dexamethasone in inpatient asthma treatment, which will have the potential to improve the delivery of asthma care, by improving compliance with a mainstay of treatment. Results will be disseminated through peer-reviewed publications, organisations and meetings.

TRIAL REGISTRATION NUMBER

NCT03133897; Pre-results.

Medication adherence in pediatric asthma: A systematic review of the literature

OBJECTIVE

To provide a systematic review of correlates of adherence to inhaled corticosteroids (ICS) in pediatric asthma across the individual, family, community, and healthcare system domains.

METHODS

Articles assessing medication adherence in pediatric asthma published from 1997 to 2016 were identified using PsychINFO, Medline, and CINAHL. Search terms included asthma, compliance, self-management, adherence, child, and youth. Search results were limited to articles: 1) published in the US; 2) using a pediatric population (0-25 years old); and 3) presenting original data related to ICS adherence. Correlates of adherence were categorized according to the domains of the Pediatric Self-Management Model. Each article was evaluated for study quality.

RESULTS

Seventy-nine articles were included in the review. Family-level correlates were most commonly reported (N = 51) and included socioeconomic status, race/ethnicity, health behaviors, and asthma knowledge. Individual-level correlates were second-most common (N = 37), with age being the most frequently identified negative correlate of adherence. Health care system correlates (N = 24) included enhanced asthma care and patient-provider communication. Few studies (N = 10) examined community correlates of adherence. Overall study quality was moderate, with few quantitative articles (26.38%) and qualitative articles (21.4%) referencing a theoretical basis for their studies.

CONCLUSIONS

All Pediatric Self-Management Model domains were correlated with youth adherence, which suggests medication adherence is influenced across multiple systems; however, most studies assessed adherence correlates within a single domain. Future research is needed that cuts across multiple domains to advance understanding of determinants of adherence.

Dexamethasone Compared to Prednisone for the Treatment of Children With Acute Asthma Exacerbations

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.

Randomized Trial of Dexamethasone Versus Prednisone for Children with Acute Asthma Exacerbations

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.

Monoclonal antibody therapy for the treatment of asthma and chronic obstructive pulmonary disease with eosinophilic inflammation

Eosinophils have been linked with asthma for more than a century, but their role has been unclear. This review discusses the roles of eosinophils in asthma and chronic obstructive pulmonary disease (COPD) and describes therapeutic antibodies that affect eosinophilia. The aims of pharmacologic treatments for pulmonary conditions are to reduce symptoms, slow decline or improve lung function, and reduce the frequency and severity of exacerbations. Inhaled corticosteroids (ICS) are important in managing symptoms and exacerbations in asthma and COPD. However, control with these agents is often suboptimal, especially for patients with severe disease. Recently, new biologics that target eosinophilic inflammation, used as adjunctive therapy to corticosteroids, have proven beneficial and support a pivotal role for eosinophils in the pathology of asthma. Nucala® (mepolizumab; anti-interleukin [IL]-5) and Cinquair® (reslizumab; anti-IL-5), the second and third biologics approved, respectively, for the treatment of asthma, exemplifies these new treatment options. Emerging evidence suggests that eosinophils may contribute to exacerbations and possibly to lung function decline for a subset of patients with COPD. Here we describe the pharmacology of therapeutic antibodies inhibiting IL-5 or targeting the IL-5 receptor, as well as other cytokines contributing to eosinophilic inflammation. We discuss their roles as adjuncts to conventional therapeutic approaches, especially ICS therapy, when disease is suboptimally controlled. These agents have achieved a place in the therapeutic armamentarium for asthma and COPD and will deepen our understanding of the pathogenic role of eosinophils.

A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department

STUDY OBJECTIVE

In acute exacerbations of asthma in children, corticosteroids reduce relapses, subsequent hospital admission, and the need for ß2-agonist bronchodilators. Prednisolone is the most commonly used corticosteroid, but prolonged treatment course, vomiting, and a bitter taste may reduce patient compliance. Dexamethasone has a longer half-life and has been used safely in other acute pediatric conditions. We examine whether a single dose of oral dexamethasone is noninferior to prednisolone in the emergency department (ED) treatment of asthma exacerbations in children, as measured by the Pediatric Respiratory Assessment Measure (PRAM) at day 4.

METHODS

We conducted a randomized, open-label, noninferiority trial comparing oral dexamethasone (single dose of 0.3 mg/kg) with prednisolone (1 mg/kg per day for 3 days) in patients aged 2 to 16 years and with a known diagnosis of asthma or at least 1 previous episode of ß2-agonist-responsive wheeze who presented to a tertiary pediatric ED. The primary outcome measure was the mean PRAM score (range of 0 to 12 points) performed on day 4. Secondary outcome measures included requirement for further steroids, vomiting of study medication, hospital admission, and unscheduled return visits to a health care practitioner within 14 days.

RESULTS

There were 245 enrollments involving 226 patients. There was no difference in mean PRAM scores at day 4 between the dexamethasone and prednisolone groups (0.91 versus 0.91; absolute difference 0.005; 95% CI -0.35 to 0.34). Fourteen patients vomited at least 1 dose of prednisolone compared with no patients in the dexamethasone group. Sixteen children (13.1%) in the dexamethasone group received further systemic steroids within 14 days after trial enrollment compared with 5 (4.2%) in the prednisolone group (absolute difference 8.9%; 95% CI 1.9% to 16.0%). There was no significant difference between the groups in hospital admission rates or the number of unscheduled return visits to a health care practitioner.

CONCLUSION

In children with acute exacerbations of asthma, a single dose of oral dexamethasone (0.3 mg/kg) is noninferior to a 3-day course of oral prednisolone (1 mg/kg per day) as measured by the mean PRAM score on day 4.

Comparative Effectiveness of Dexamethasone versus Prednisone in Children Hospitalized with Asthma

OBJECTIVES

To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children hospitalized with asthma exacerbation not requiring intensive care.

STUDY DESIGN

This multicenter retrospective cohort study, using the Pediatric Health Information System, included children aged 4-17 years who were hospitalized with a principal diagnosis of asthma between January 1, 2007 and December 31, 2012. Children with chronic complex condition and/or initial intensive care unit (ICU) management were excluded. Propensity score matching was used to detect differences in length of stay (LOS), readmissions, ICU transfer, and cost between groups.

RESULTS

40,257 hospitalizations met inclusion criteria; 1166 (2.9%) received only dexamethasone. In the matched cohort (N = 1284 representing 34 hospitals), the LOS was significantly shorter in the dexamethasone group compared with the prednisone/prednisolone group. The proportion of subjects with a LOS of 3 days or more was 6.7% in the dexamethasone group and 12% in the prednisone/prednisolone group (P = .002). Differences in all-cause readmission at 7- and 30 days were not statistically significant. The dexamethasone group had lower costs of index admission ($2621 vs $2838; P < .001) and total episode of care (including readmissions) ($2624 vs $2856; P < .001) compared with the prednisone/prednisolone group. There were no clinical significant differences in ICU transfer or readmissions between groups.

CONCLUSIONS

Dexamethasone may be considered an alternative to prednisone/prednisolone for children hospitalized with asthma exacerbation not requiring admission to intensive care.

Identifying parental preferences for corticosteroid and inhaled beta-agonist delivery mode in children with acute asthma exacerbations

This study examines caregiver preferences of single-dose dexamethasone (DEX) versus 5-day oral prednisolone in treating acute asthma exacerbation in a pediatric emergency department (PED). A secondary objective was preference for mode of home inhaled β-agonist administration. Caregivers of patients 2 to 18 years with an acute asthma exacerbation treated in the PED completed a 1-page questionnaire including asthma history and preferences for steroids and β-agonist administration. One hundred caregivers completed the questionnaire. Within the preceding year, 79% had an asthma exacerbation and 73.7% (n = 99) were prescribed prednisolone. DEX was preferred by 79% of caregivers. Preferences were independent of caregiver demographics except in cases of prior intensive care admission, where DEX was less favored (odds ratio = 0.27, P < .046). No difference existed in mode of home β-agonist administration. Most caregivers prefer DEX in acute asthma exacerbation management. No difference exists for home β-agonists. These results may advise clinical practice in pediatric acute asthma exacerbation.

Is dexamethasone an effective alternative to oral prednisone in the treatment of pediatric asthma exacerbations?

BACKGROUND

A short course of systemic corticosteroids is an important therapy in the treatment of pediatric asthma exacerbations. Although a 5-day course of oral prednisone or prednisolone has become the most commonly used regimen, dexamethasone has also been used for a shorter duration (1-2 days) with potential for improvement in compliance and palatability. We reviewed the literature to determine if there is sufficient evidence that dexamethasone can be used as an effective alternative in the treatment of pediatric asthma exacerbations in the inpatient setting.

METHODS

A Medline search was conducted on the use of dexamethasone in the treatment of asthma exacerbations in children. The studies selected were clinical trials comparing the efficacy of dexamethasone with prednisone. Meta-analysis was performed examining physician revisitation rates and symptomatic return to baseline.

RESULTS

Six completed pediatric clinical trials met the inclusion criteria. All of the pediatric trials found that prednisone is not superior to dexamethasone in treating mild to moderate asthma exacerbations. Meta-analysis demonstrated homogeneity between the dexamethasone and prednisone groups when examining symptomatic return to baseline and unplanned physician revisits after the initial emergency department encounter. Some studies found potential additional benefits of dexamethasone, including improved compliance and less vomiting.

CONCLUSIONS

The current literature suggests that dexamethasone can be used as an effective alternative to prednisone in the treatment of mild to moderate acute asthma exacerbations in children, with the added benefits of improved compliance, palatability, and cost. However, more research is needed to examine the role of dexamethasone in hospitalized children.

Parental preference for short- versus long-course corticosteroid therapy in children with asthma presenting to the pediatric emergency department

Asthma is the most common chronic condition affecting children and a prominent chief complaint in pediatric emergency departments (ED). We aimed to determine parental preference between short- and long-term courses of oral corticosteroids for use in children with mild to moderate asthma presenting to our pediatric ED with acute asthma exacerbations. We surveyed parents of asthmatic children who presented to our pediatric ED from August 2011 to April 2012. Questions characterized each patient's asthma severity, assessed parental preference among systemic steroid and inhaled medication delivery options for acute asthma management, and inquired about compliance, medication costs, and intention to follow up. The majority of our parents prefer the use of 1 to 2 days of steroids to 5 days for acute asthma exacerbations in the ED. Thus, dexamethasone is an attractive alternative to prednisone/prednisolone and should be considered in the management of acute asthma exacerbations in the ED.

Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest?

OBJECTIVES

Many patients are discharged from the emergency department (ED) with an incomplete understanding of the information needed to safely care for themselves at home. Patients have demonstrated particular difficulty in understanding post-ED care instructions (including medications, home care, and follow-up). The objective of this study was to further characterize these deficits and identify gaps in knowledge that may place the patient at risk for complications or poor outcomes.

METHODS

This was a prospective cohort, phone interview-based study of 159 adult English-speaking patients within 24 to 36 hours of ED discharge. Patient knowledge was assessed for five diagnoses (ankle sprain, back pain, head injury, kidney stone, and laceration) across the following five domains: diagnosis, medications, home care, follow-up, and return instructions. Knowledge was determined based on the concordance between direct patient recall and diagnosis-specific discharge instructions combined with chart review. Two authors scored each case independently and discussed discrepancies before providing a final score for each domain (no, minimal, partial, or complete comprehension). Descriptive statistics were used for the analyses.

RESULTS

The study population was 50% female with a median age of 41 years (interquartile range [IQR] = 29 to 53 years). Knowledge deficits were demonstrated by the majority of patients in the domain of home care instructions (80%) and return instructions (79%). Less frequent deficits were found for the domains of follow-up (39%), medications (22%), and diagnosis (14%). Minimal or no understanding in at least one domain was demonstrated by greater than two-thirds of patients and was found in 40% of cases for home care and 51% for return instructions. These deficits occurred less frequently for domains of follow-up (18%), diagnosis (3%), and medications (3%).

CONCLUSIONS

Patients demonstrate the most frequent knowledge deficits for home care and return instructions, raising significant concerns for adherence and outcomes.

The Joint Commission Children's Asthma Care quality measures and asthma readmissions

BACKGROUND AND OBJECTIVES

The Joint Commission introduced 3 Children's Asthma Care (CAC 1-3) measures to improve the quality of pediatric inpatient asthma care. Validity of the commission's measures has not yet been demonstrated. The objectives of this quality improvement study were to examine changes in provider compliance with CAC 1-3 and associated asthma hospitalization outcomes after full implementation of an asthma care process model (CPM).

METHODS

The study included children aged 2 to 17 years who were admitted to a tertiary care children's hospital for acute asthma between January 1, 2005, and December 31, 2010. The study was divided into 3 periods: preimplementation (January 1, 2005-December 31, 2007), implementation (January 1, 2008-March 31, 2009), and postimplementation (April 1, 2009-December 31, 2010) periods. Changes in provider compliance with CAC 1-3 and associated changes in hospitalization outcomes (length of stay, costs, PICU transfer, deaths, and asthma readmissions within 6 months) were measured. Logistic regression was used to control for age, gender, race, insurance type, and time.

RESULTS

A total of 1865 children were included. Compliance with quality measures before and after the CPM implementation was as follows: 99% versus 100%, CAC-1; 100% versus 100%, CAC-2; and 0% versus 87%, CAC-3 (P < .01). Increased compliance with CAC-3 was associated with a sustained decrease in readmissions from an average of 17% to 12% (P = .01) postimplementation. No change in other outcomes was observed.

CONCLUSIONS

Implementation of the asthma CPM was associated with improved compliance with CAC-3 and with a delayed, yet significant and sustained decrease in hospital asthma readmission rates, validating CAC-3 as a quality measure. Due to high baseline compliance, CAC-1 and CAC-2 are of questionable value as quality measures.

Single dose oral dexamethasone versus multi-dose prednisolone in the treatment of acute exacerbations of asthma in children who attend the emergency department: study protocol for a randomized controlled trial

Background

Asthma is a major cause of pediatric morbidity and mortality. In acute exacerbations of asthma, corticosteroids reduce relapses, subsequent hospital admission and the need for ß₂-agonist therapy. Prednisolone is relatively short-acting with a half-life of 12 to 36 hours, thereby requiring daily dosing. Prolonged treatment course, vomiting and a bitter taste may reduce patient compliance with prednisolone. Dexamethasone is a long-acting corticosteroid with a half-life of 36 to 72 hours. It is used frequently in children with croup and bacterial meningitis, and is well absorbed orally. The purpose of this trial is to examine whether a single dose of oral dexamethasone (0.3 mg/kg) is clinically non-inferior to prednisolone (1 mg/kg/day for three days) in the treatment of exacerbations of asthma in children who attend the Emergency Department.

Methods/design

This is a randomized, non-inferiority, open-label clinical trial. After informed consent with or without assent, patients will be randomized to either oral dexamethasone 0.3 mg/kg stat or prednisolone 1 mg/kg/day for three days. The primary outcome measure is the comparison between the Pediatric Respiratory Assessment Measure (PRAM) across both groups on Day 4. The PRAM score, a validated, responsive and reliable tool to determine asthma severity in children aged 2 to 16 years, will be performed by a clinician blinded to treatment allocation. Secondary outcomes include relapse, hospital admission and requirement for further steroid therapy. Data will be analyzed on an intention-to-treat and a per protocol basis. With a sample size of 232 subjects (105 in each group with an estimated 10% loss to follow-up), we will be able to reject the null hypothesis - that the population means of the experimental and control groups are equal with a probability (power) of 0.9. The Type I error probability associated with this test (of the null hypothesis) is 0.05.

Discussion

This clinical trial may provide evidence that a shorter steroid course using dexamethasone can be used in the treatment of acute pediatric asthma, thus eliminating the issue of compliance to treatment.

Registration

ISRCTN26944158 and EudraCT Number 2010-022001-18

A cost-effectiveness analysis of dexamethasone versus prednisone in pediatric acute asthma exacerbations

OBJECTIVES

The objective was to evaluate the cost-effectiveness of dexamethasone versus prednisone for the treatment of pediatric asthma exacerbations in the emergency department (ED).

METHODS

This was a cost-effectiveness analysis using a decision analysis model to compare two oral steroid options for pediatric asthma patients: 5 days of oral prednisone and 2 days of oral dexamethasone (with two dispensing possibilities: either a prescription for the second dose or the second dose dispensed at the time of ED discharge). Using estimates from published studies for rates of prescription filling, compliance, and steroid efficacy, the projected rates of ED relapse visits, hospitalizations within 7 to 10 days of the sentinel ED visit, direct costs, and indirect costs between the two arms were compared.

RESULTS

The rate of return to the ED per 100 patients within 7 to 10 days of the sentinel ED visit for the prednisone arm was 12, for the dexamethasone/prescription arm was 10, and for the dexamethasone/dispense arm was 8. Rates of hospitalization per 100 patients were 2.8, 2.4, and 1.9, respectively. Direct costs per 100 patients for each arm were $20,500, $17,200, and $13,900, respectively. Including indirect costs related to missed parental work, total costs per 100 patients were $22,000, $18,500, and $15,000, respectively. Total cost savings per 100 patients for the dexamethasone/prescription arm compared to the prednisone arm was $3,500 and for the dexamethasone/dispense arm compared to the prednisone arm was $7,000.

CONCLUSIONS

This decision analysis model illustrates that use of 2 days of dexamethasone instead of 5 days of prednisone at the time of ED visit for asthma leads to a decreased number of ED visits and hospital admissions within 7 to 10 days of the sentinel ED visit and provides cost savings.

Medication adherence in the asthmatic child and adolescent

Asthma is a common inflammatory condition affecting more than 7 million children in the United States alone, and tens of millions more globally. Despite effective preventive medications, medication nonadherence in children and adolescents is alarmingly high. Nonadherence can result in poor asthma control, which leads to decreased quality of life, lost productivity, increased health care utilization, and even the risk of death. Nonadherence in children and adolescents deserves special attention because they face unique barriers to adherence that change with age. Young children depend on adults for the delivery of asthma care, and their care is strongly influenced by parental motivation and attitudes and the home environment. As these children enter adolescence, they typically assume responsibility for their asthma care at the same time that they are claiming their independence and possibly experimenting with high-risk behaviors. Morbidity and mortality, as well as nonadherence, appear to be greatest among adolescents and minority children. Although no perfect tool for measuring adherence exists, objective methods, such as electronic monitoring, can provide valuable information to health care providers. Beyond asthma self-management and education, no specific resource-heavy adherence interventions have proven consistently helpful. However, large-scale, well-designed studies on this subject are lacking. In light of the fact that nonadherence is a potentially modifiable factor that impacts on morbidity and mortality, it is worth pursuing further research to determine better interventions. It is likely, however, that no one answer exists, and interventions will need to be tailored to specific at-risk populations.

Effects of a peer-led asthma self-management program for adolescents

OBJECTIVE

To evaluate the effectiveness of a peer-led asthma self-management program for adolescents.

DESIGN

Randomized controlled trial comparing a peer-led asthma program (intervention group) and a conventional adult-led asthma program (control group). Each program was implemented at a full-day camp.

SETTING

A city and adjacent suburbs in upstate New York.

PARTICIPANTS

A total of 112 adolescents aged 13 to 17 years with persistent asthma.

INTERVENTION

A peer-led asthma self-management program implemented at a day camp.

MAIN OUTCOME MEASURES

The Child Attitude Toward Illness Scale and the Paediatric Asthma Quality of Life Questionnaire were administered at baseline and immediately and 3, 6, and 9 months after the intervention. Spirometry was conducted twice: before and 9 months after the intervention.

RESULTS

The intervention group reported more positive attitudes at 6 months (mean difference, 4.11; 95% confidence interval [CI], 0.65-7.56) and higher quality of life at 6 months (difference, 11.38; 95% CI, 0.96-21.79) and 9 months (difference, 12.97; 95% CI, 3.46-22.48) than the control group. The intervention was found to be more beneficial to adolescents of male gender or low family income, as shown by greater improvement in positive attitudes toward asthma and quality of life than their counterparts.

CONCLUSION

An asthma self-management program led by peer leaders is a developmentally appropriate approach that can be effective in assisting adolescents with asthma in improving their attitudes and quality of life, particularly for males and those of low socioeconomic status.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01161225.

Medication nonfulfillment rates and reasons: narrative systematic review

BACKGROUND

The literature on nonfulfillment of prescription medications spans over three decades of work. There is a wide variation in reported nonfulfillment rates, but no previous study has systematically reviewed this literature to explore the reasons behind this variation.

OBJECTIVE

The objective of this study was to review estimates of medication nonfulfillment rates and published reasons for nonfulfillment and explore whether nonfulfillment rates vary by study variables.

METHODS

Articles were identified through searches conducted on MEDLINE, CINAHL, Psych Info, and EMBASE, and review of relevant reference citations. Methodological variables, nonfulfillment rate, and unit of analysis (i.e., patient or prescription) were abstracted from each article selected for review. Mean and median nonfulfillment rates for groups categorized by unit of analysis and selected methodological variables (method for assessing nonfulfillment, sample characteristics, disease subgroup, sample size, country of data collection, recall period or time allowed before classifying as nonfulfillment, and year of study) were calculated. Reasons for nonfulfillment were abstracted from all articles that included a relevant discussion.

FINDINGS

A total of 79 studies reporting pure nonfulfillment rates (59 at the patient level and 20 at the prescription level) and six studies reporting nonfulfillment rates in combination with nonpersistence rates were included. There was a wide variation in nonfulfillment rates reported by the studies - from 0.5% to 57.1%. The three primary reasons for nonfulfillment identified from this review were perceived concerns about medications, lack of perceived need for medications, and medication affordability issues.

CONCLUSION

To the best of the authors' knowledge, this study is the first narrative systematic review on nonfulfillment of prescription medications. Despite the wide variation in individual study rates, the mean and median rates across different modes of data collection and sources of data were in a relatively narrow range (11% to 19%) and surprisingly close to the overall mean (16.4%) and median (15%.0) rates for all studies. The reasons for nonfulfillment identified through this review address barriers to nonfulfillment at the patient, physician, and health system level and thus bear important implications for policy makers.

Can montelukast shorten prednisolone therapy in children with mild to moderate acute asthma? A randomized controlled trial

OBJECTIVE

To examine whether outpatient post-stabilization therapy with montelukast produces more treatment failures than prednisolone.

STUDY DESIGN

In this randomized, double-blind, double-dummy non-inferiority trial, 130 children 2 to 17 years of age with mild to moderate acute asthma stabilized with prednisolone in the emergency department received 5 daily treatments with either prednisolone or montelukast after discharge. The primary outcome was treatment failure within 8 days (ie, an asthma-related unscheduled visit, hospitalization, or additional systemic corticosteroids).

RESULTS

The rates of treatment failure were 7.9% in the prednisolone group and 22.4% in the montelukast group (95% CI, 26.5%-2.4%). Treatment was more likely to fail in younger patients (odds ratio, 4.9). In the montelukast group, more patients received additional pharmacotherapy than in patients receiving prednisolone (23.9% versus 9.5%, P = .03). The differences in the daily salbutamol treatments, asymptomatic days, and changes in the Pediatric Respiratory Assessment Measure score were not significant (P = .85, .75, and .26, respectively).

CONCLUSION

Montelukast does not represent an adequate alternative to corticosteroids after outpatient stabilization in mild to moderate acute asthma. This population should receive oral corticosteroids after discharge.

Demographic, socioeconomic, and psychological factors related to medication non-adherence among emergency department patients

BACKGROUND

Many Emergency Department (ED) visits are related to medication non-adherence; however, the contributing factors are poorly understood.

OBJECTIVES

To explore the relative contributions of demographic, socioeconomic, and psychological factors to medication non-adherence in an ED population.

METHODS

This was a cross-sectional analysis enrolling patients with one of three illnesses requiring chronic medication usage (hypertension, diabetes, or seizures). Trained research associates administered a 60-item survey that assessed demographic and socioeconomic information, as well as a variety of psychological factors potentially relevant to adherence (health attitudes, health beliefs, depression, anxiety, social support, and locus of control). Patients rated their overall prescription medication adherence and estimated the number of days in the preceding month on which doses were missed. In addition, treating physicians estimated the degree to which the ED visit was related to medication non-adherence; clinical data were abstracted to help validate patient and physician assessments. The relationships between non-adherence and demographic, socioeconomic, and psychological variables were explored using multivariate statistics and logistic regression. Covariance analysis was performed to validate subscales, and receiver-operator curves were used to define optimal threshold values.

RESULTS

A total of 472 patients consented to participate, with good representation for various demographic and socioeconomic groups. Each psychological factor related significantly to both patient and physician ratings of non-adherence (p < 0.05). Of all demographic and socioeconomic factors examined, only current or historical drug use predicted non-adherence.

CONCLUSIONS

Psychological factors seem to be important determinants of medication non-adherence among ED patients. These data may help define future research directions and interventions.

[General practitioners' perception of the impact of corticosteroid-induced adverse events]

BACKGROUND

General practitioners' perception of the discomfort their patients experience because of corticosteroid-induced adverse events is unknown.

METHODS

An observational epidemiological study was conducted in September 2007. Eight hundred and sixty general practitioners belonging to the réseau Sentinelles were asked to complete an electronical questionnaire. The questionnaire aimed to assess their perception of discomfort induced by adverse events induced by a long-term (i.e.,>or=3 months) corticosteroid therapy among their patients. Results were compared with the declaration made by 115 long-term corticosteroid treated patients followed in an internal medicine department.

RESULTS

Two hundred and ninety-three general practitioners responded to the questionnaire (response rate: 34%). They were predominantly male (87%). Forty-eight percent of them reported 400 to 600 monthly visits. The mean length of corticosteroid therapy for patients was 44+/-38 months and the mean daily dosage was 15+/-14 mg. They suffered mainly from lupus erythematosus (33%) or giant cell arteritis (15%). The adverse events considered to be the most disturbing by patients were lipodystrophy (25%), followed by weight gain (18%) and neuropsychiatric complaints (16%). Physicians widely overestimated the discomfort caused by weight gain cited as the most disturbing adverse event by 59% of them and underestimated that induced by mood disorders cited as the most disturbing by only 3% of them.

CONCLUSION

The discomfort caused by corticosteroid-induced neuropsychiatric adverse events are underestimated by general practitioners.

Pearls and pitfalls of community-based group interventions for adolescents: lessons learned from an adolescent asthma cAMP study

This paper explores specific challenges in implementing community-based group interventions with adolescents and makes practical suggestions to researchers who contemplate the group approach. Group interventions have important implications for adolescent research and program development in the area of chronic illness. They have a capacity to address participants' psychosocial needs as well as to offer a cost and time-effective opportunity for disease-specific education. A group intervention encompasses an array of pragmatic challenges that need to be addressed through meticulous preparation. Based on the authors' firsthand experience with a group intervention for adolescents with asthma, this paper describes potential difficulties and logistics pertaining to recruitment, planning and implementation of a group intervention targeting adolescents and suggests general strategies that can be adopted.

Pearls and pitfalls of community-based group interventions for adolescents: lessons learned from an adolescent asthma cAMP study

This paper explores specific challenges in implementing community-based group interventions with adolescents and makes practical suggestions to researchers who contemplate the group approach. Group interventions have important implications for adolescent research and program development in the area of chronic illness. They have a capacity to address participants' psychosocial needs as well as to offer a cost and time-effective opportunity for disease-specific education. A group intervention encompasses an array of pragmatic challenges that need to be addressed through meticulous preparation. Based on the authors' firsthand experience with a group intervention for adolescents with asthma, this paper describes potential difficulties and logistics pertaining to recruitment, planning and implementation of a group intervention targeting adolescents and suggests general strategies that can be adopted.

[Therapeutic education in asthma management]

All guidelines, protocols and recommendations underline the importance of therapeutic education as a key element in asthma management and control. Considerable evidence supports the efficacy and effectiveness of this measure. Health personnel, as well as patients and their parents, can and should be educated with two main objectives: to achieve the best possible quality of life and to allow self control of the disease. These goals can be attained through an educational process that should be individually tailored, continuous, progressive, dynamic, and sequential. The process poses more than a few difficulties involving patients, health professionals, and the health systems. Knowledge of the various psychological factors that can be present in asthmatic patients, as well as the factors related to the highly prevalent phenomenon of non-adherence, is essential. Awareness of the factors influencing physician-patient-family communication is also highly important to achieve the objectives set in therapeutic education. The educational process helps knowledge and abilities to be acquired and allows attitudes and beliefs to be modified. Patients and caregivers should be provided with an individual written action plan based on symptoms and/or forced expiratory volume in 1 second. Periodic follow-up visits are also required.

The impact of parents' medication beliefs on asthma management

BACKGROUND

Previous studies suggest a relationship between parental beliefs about asthma medications and medication adherence. It is not clear how parents' positive and negative feelings about medications interact to influence medication adherence.

OBJECTIVES

The objectives of this study were to describe parents' perceived need for and concerns about their child's asthma medications and to assess the weighted impact of these positive and negative beliefs on parent-reported adherence.

METHODS

We conducted a cross-sectional survey of parents of children with asthma in southeast Michigan; response rate was 71%. Children with reported use of a preventive asthma medication were included (n = 622). We used a validated Beliefs About Medications Questionnaire (2 subscales: necessity and concern) to assess parents' positive and negative attitudes about their child's medications. To measure how parents weigh these beliefs, we also calculated a necessity-concern differential score (difference between necessity and concern subscales). We used a 4-item parent-report scale to measure medication adherence.

RESULTS

The majority of children were nonminority. Overall, 72% of parents felt that their child's asthma medications were necessary, and 30% had strong concerns about the medications. For 77% of parents, necessity scores were higher than concern scores, and for 17%, concern exceeded necessity. Nonminority parents were more likely to have necessity scores exceed concern scores compared with minority parents (79% vs 68%). Mean adherence scores increased as the necessity-concern differential increased. In a multivariate mixed-model regression, a greater necessity-concern differential score and being nonminority predicted better adherence.

CONCLUSIONS

These findings confirm a relationship between medication beliefs and adherence among parents of children with asthma. A better understanding of parents' medication beliefs and their impact on adherence may help clinicians counsel effectively to promote adherence.

Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma

OBJECTIVE

To compare the efficacy of a single dose of oral dexamethasone (Dex) versus 5 days of twice-daily prednisolone (Pred) in the management of mild to moderate asthma exacerbations in children.

STUDY DESIGN

A prospective, randomized, double-blinded trial of children 2 to 16 years of age who presented to the emergency department (ED) with acute mild to moderate asthma exacerbations. Subjects received single-dose oral Dex (0.6 mg/kg to a maximum of 18 mg) or oral Pred (1 mg/kg per dose to a maximum of 30 mg) twice daily for 5 days. After discharge, subjects were contacted by telephone at 48 h to assess symptoms and reevaluated in the ED in 5 days. The primary outcome was the number of days needed for Patient Self Assessment Score to return to baseline (score of 0-0.5).

MAIN RESULTS

Baseline characteristics of the 2 groups were similar. The mean number of days needed for Patient Self Assessment Score to return to baseline (0-0.5) in the Dex and Pred groups were 5.21 versus 5.22 days, respectively (mean difference, -0.01; confidence interval, -0.70, 0.68). Pulmonary index scores were similar in both groups at initial presentation, initial ED discharge and at the day 5 follow-up visit. At the first visit, mean time to discharge was 3.5 h (+/-1.93)for Dex and 4.3 h (+/-3.67) for Pred (mean difference, -0.8; confidence interval, -1.8, 0.2). Initial admission rate was 9% (Dex) versus 13.4% (Pred). There was no significant difference in the number of salbutamol therapies needed in the ED nor at home after discharge. For subjects discharged home, the admission rate after initial discharge was 4.9% (Dex) versus 1.8% (Pred), resulting in overall hospital admission rates of 13.4% (Dex) and 14.9% (Pred).

CONCLUSION

A single dose of oral Dex (0.6 mg/kg) is no worse than 5 days of twice-daily prednisolone (1 mg/kg per dose) in the management of children with mild to moderate asthma.