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Oral Corticosteroids For Asthma Exacerbation

How Effective Is Prednisone For Asthma

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A review article in American Journal of Medicine evaluated six different trials for adults with acute asthma episodes. In these trials, people received corticosteroid treatment within 90 minutes of arriving at the emergency room. Researchers found that these groups had lower hospital admittance rates than people who received a placebo instead.

Additionally, a review on management of acute asthma attacks in American Family Physician found that people sent home with a 5- to 10-day prescription of 50 to 100 milligrams of oral prednisone had a decreased risk of relapse of asthma symptoms. The same review states that in children 2 to 15 years old, three days of prednisone therapy at 1 mg per kilogram of body weight can be as effective as five days of prednisone therapy.

Side effects of prednisone can include:

  • fluid retention

Risk Of Bias Assessment And Statistical Analysis

The Cochrane Collaboration risk assessment tool for RCTs was selected for quality assessment of the included trials . Every study was evaluated for the following variables: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases. We rated studies on each variable as low risk, high risk, or unclear risk of bias.

Anticipating heterogeneity amongst studies, a random-effects model was used to calculate the pooled effect size. Categorical data were summarized using the Mantel-Haenszel Risk Ratio with 95% confidence intervals . Heterogeneity was calculated using the I2 statistic. I2 values of 2550% represented low, values of 5075% medium and more than 75% represented substantial heterogeneity. A sensitivity analysis was carried out to assess the influence of each study on the pooled effect size. Sub-group analysis was conducted for relapse rates based on follow-up period and dosage of dexamethasone. Using the method described by Muncer et al. , power of included studies for the every variable was calculated. The software Review Manager was used for the meta-analysis. Gpower software was used to calculate the power of studies.

How Do Steroids Help Asthma

The steroids used to treat asthma are known as corticosteroids. Corticosteroids are copies of hormones your body produces naturally.

Steroids help asthma by calming inflamed airways and stopping inflammation. This helps ease asthma symptoms such as breathlessness and coughing. It will also help prevent your lungs reacting to triggers.

Youre more likely to avoid high doses of steroids if you take your preventer inhaler every day as prescribed, says Dr Andy Whittamore, Asthma UKs in-house GP.

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Strengths And Limitations Of This Study

  • The proposed work will be the largest published cohort study exploring determinants of responsiveness to oral corticosteroids in children treated according to evidence-based acute asthma guidelines.

  • The documentation of exposure using biomarkers to confirm parental reports enhances accuracy and precision of the determinants.

  • The selection of a primary endpoint, that is, failure of emergency department management, the only clinical outcome that can be documented in all patients irrespective of age, carries enormous weight for modifying practice.

  • A prospective cohort study is subject to potential biases inherent to this design. Loss to follow-ups will be quasi non-existent for the main and most secondary outcomes due to the short duration of follow-up in the emergency department. Confounding by indication will be minimised by the standardised severity-specific therapy.

  • The inherent variability of admission and assessment of the Paediatric Respiratory Assessment Measure add noise to the data, which was taken into account in the sample size.

History Of Oral Corticosteroids Use In Asthma

An Autoimmune Arthritic Systemic Life©: Corticosteroids and Severe ...

Before the 1950s, the treatment for asthma was restricted to those compounds that were either plant-derived or adrenaline derivatives. This treatment consisted primarily of bronchodilator agents.4 With the development of steroid and adrenocorticotropic hormone extracts, a 1952 seminal study by McCombs noted the marked improvement that could be derived with respect to asthma symptoms and control using either corticosteroids or adrenocorticotropic hormone.5 It has since been determined that oral and parenteral corticosteroids have no significant difference in bioavailability, and thus oral corticosteroids are by far the most common formulation of systemic corticosteroid used in the treatment of asthma today. It was not until 1958 that the association between successful treatment with OCS and a reduction in eosinophils in the sputum was noted.6 This revelation opened the door to widespread treatment with OCS, both on a chronic and acute basis,4 but with this came increasing recognition of the side effects of systemic corticosteroids. The subsequent development of inhaled corticosteroids and the recognition that these can be equally as effective in the majority of patients with asthma, therefore, led to a decline in the use of OCS, except in the population with severe asthma.7

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Why Might You Need Long Term Oral Corticosteroids

If you have severe asthma, you might be prescribed oral corticosteroids long term. This could be months or even years. Your doctor or specialist will only prescribe this if it is necessary to prevent you from having regular flare-ups.

If you are prescribed long term oral corticosteroids, ask your doctor or specialist if any monoclonal antibodies are suitable for you. Monoclonal antibodies could reduce or eliminate your need for long term oral corticosteroids.

Barriers To And Solutions For Change

A systematic approach addressing patient, prescriber and healthcare system barriers is required to reduce unnecessary OCS use and minimize unwanted side effects . A substantial challenge, however, lies in the diverse group of clinicians who administer OCS, especially for acute use. Education campaigns highlighting OCS benefit and risk trade-offs, and increased awareness of steroid-sparing strategies are essential to change entrenched prescribing patterns.

Figure 2

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When Will Your Doctor Prescribe Steroids For Your Asthma

Your doctor will prescribe steroids for your asthma if you need extra help with symptoms. Theyll prescribe the lowest dose of steroid medicines you need to treat your asthma symptoms and keep you well.

For example, your GP will prescribe steroid medicine if:

  • youre taking your reliever inhaler three or more times a week. Most people with asthma are prescribed a steroid preventer inhaler to use every day. It stops inflammation building up in your airways and cuts your risk of symptoms. So, if youve only been given a reliever inhaler, and youre using it three or more times a week, see your GP.
  • youve had an asthma attack. You might be given a short course of steroid tablets to take until your symptoms are fully under control. These can quickly get the swelling in your airways back down again if you have an asthma attack.
  • youre getting asthma symptoms even when youre taking your preventer inhaler as prescribed. This is when a course of steroid tablets may be what you need to get your asthma back under control.

If your asthma is still not well controlled in spite of high dose inhaled steroids, keep taking them until you can discuss your treatment with your GP. Use our severe asthma tool to find out if you need a referral to a severe asthma specialist.

Long Term Use Of Oral Corticosteroids For Asthma

“Management of Severe Asthma Exacerbation” by Roubing Wang for OPENPediatrics

Current asthma guidelines recommend advancing asthma treatment in a step-wise fashion to reach disease control, for both improvement in symptoms and prevention of exacerbations.23 This step-wise progression begins with low dose inhaled corticosteroids, then, if necessary, it progresses to inhaled corticosteroids combined with long-acting -agonists, which will control most cases of asthma. Until recently, regular use of OCS was often the only effective option for those with severe disease that could not be controlled with the previous steps. Contemporary research has therefore focused on optimal dosing, and a Cochrane review has confirmed that OCS treatment that is titrated based on sputum eosinophil counts results in reductions in exacerbation rates compared with dosing based on clinical markers alone.24 The options have recently expanded and now include inhaled long-acting anticholinergic therapies and biological agents that directly target IgE and IL-5. Currently, the latter only have a role in patients who have severe allergic or eosinophilic asthma refractory to treatment with inhaled corticosteroids or long-acting -agonists, and can only be prescribed by specialists. When used appropriately, these biological agents are effective at reducing exacerbations and improving symptoms and control.25 In view of their more acceptable side effect profiles, they are often preferentially selected, when available, over the initiation or dose escalation of long term OCS.26

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How Do Oral Corticosteroids Help Asthma

Oral corticosteroids are a powerful anti-inflammatory medicine which helps by quickly reducing the swelling in your lungs. They are much stronger than the inhaled corticosteroid in preventer inhalers. They usually only take up to 1-2 hours to start working.

Most people should not need to rely on oral corticosteroids to keep their asthma under control. Frequent or long-term use of oral corticosteroids increases your chance of side effects. It is much safer to take a daily preventer, then rely on having high dose oral corticosteroids to treat a flare-up.

Economic Impact Of Scs

While the benefits of short courses of SCS outweigh the risks in patients with acute asthma, we believe these therapies are not warranted in all patients who currently receive them. As well as the health risks of short-course SCS, the economic impact of their use should be noted. Although SCS are inexpensive medications, SCS-related comorbidities/complications pose a high cost to the health system. The direct cost of steroid-induced morbidity in asthma is of major interest and concern .

A recent study in the UK showed a significant association between the extent of corticosteroid exposure and the number of comorbidities in patients with asthma. Furthermore, healthcare costs increased with corticosteroid exposure. In this study, data from the Optimum Patient Care Research Database were analysed for patients who had received at least four short courses of SCS in the previous 2years versus patients with milder asthma or without asthma. Estimated annual cost of corticosteroid-induced morbidity in asthma was nearly six times higher for patients with high- versus low-SCS exposure .

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Other Therapeutic Options To Reduce Asthma Exacerbations

Several other therapies can optimize asthma control and reduce acute exacerbations, potentially limiting OCS bursts. However, definitive data that macrolides or tiotropium have an OCS-sparing effect require further clinical trials.

Medium-high dose ICS/LABA or ICS/formoterol maintenance and reliever

Medium- or high-dose ICS/LABA and ICS/formoterol as single maintenance and reliever therapy are the recommended GINA Step 4 treatments for patients with severe asthma. The latter approach prolongs time to first exacerbation and reduces the overall risk of exacerbation requiring OCS, emergency presentation or hospitalization by â¥25% compared with fixed ICS/LABA dosing.

Macrolides

A randomized, double-blind, placebo-controlled trial showed that add-on azithromycin 500âmg three times weekly in adults with persistent symptomatic asthma, despite ICS and LABA maintenance therapy, reduced the frequency of asthma exacerbations by 41% over 48âweeks versus placebo .

Tiotropium

Add-on tiotropium in two replicate, randomized, placebo-controlled trials involving 912 patients with uncontrolled asthma despite high-dose ICS and LABA increased the time to first severe exacerbation compared to placebo, with an overall reduction of 21% .

Bronchial thermoplasty

Different Doses And Durations Of Oral Steroids For Asthma Attacks

Iv steroids copd exacerbation

Background: People with asthma sometimes have asthma attacks, wherein their symptoms such as cough, chest tightness and difficulty breathing become worse. Many patients with asthma attacks are treated with steroids, which are usually given as a short course of tablets or liquid medicine. Steroids work by reducing inflammation in the airways in the lungs, but they can have side effects .

Review question: We set out to compare different doses or durations of oral steroids given to people having asthma attacks. This is an important issue because different doses and durations of oral steroids are used for asthma attacks in different countries, and we do not know which regimen is most likely to improve symptoms while minimising unpleasant side effects.

Study characteristics: We included 18 studies involving 2438 adults and children. Studies compared two types of steroid – prednisolone and dexamethasone – or two different doses or durations of either drug. The smallest study included just 15 people, and the largest 638. Studies followed people for between seven days and six months to see what happened to them. The evidence presented here is current to April 2016.

Any changes to the way in which asthma attacks are currently managed with oral steroids would need to be supported by larger studies than have been conducted so far.

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Questions To Ask Your Doctor

Prednisone isnt safe to take while pregnant. You should immediately let your doctor know if you become pregnant while taking prednisone.

Because prednisone acts on the immune system, you may become more susceptible to infections. You should talk to your doctor if you have an ongoing infection or have recently received a vaccine.

There are a number of medications that can interact negatively with prednisone. Its important that your doctor be informed of all of the medications youre taking. You should talk to your doctor if youre currently taking any of the following types of medication:

There are other anti-inflammatory drugs that can be used as part of asthma treatment. These include:

How Much Will I Take

Prednisone is available as an oral tablet or oral liquid solution in the United States. While similar, prednisone isnt the same as methylprednisolone, which is available as an injectable solution as well as an oral tablet. Typically, oral prednisone is used as a first-line therapy for acute asthma because its both easier to take and less expensive.

The average length of prescription for corticosteroids such as prednisone is 5 to 10 days. In adults, a typical dosage rarely exceeds 80 mg. The more common maximum dose is 60 mg. Dosages greater than 50 to 100 mg per day arent shown to be more beneficial for relief.

If you miss a dose of prednisone, you should take the missed dose as soon as you remember. If its almost time for your next dose, skip the missed dose and take the next regularly scheduled dose.

You should never take an extra dose to make up for a dose that youve missed. In order to prevent an upset stomach, its best to take prednisone with food or milk.

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Oral Corticosteroid Prescribing For Children With Asthma In A Medicaid Managed Care Program

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Dr Farber serves as the Associate Medical Director for Texas Childrens Health Plan the other authors have indicated they have no financial relationships relevant to this article to disclose.

Pediatrics

Harold J. Farber, Edwin A. Silveira, Douglas R. Vicere, Viral D. Kothari, Angelo P. Giardino Oral Corticosteroid Prescribing for Children With Asthma in a Medicaid Managed Care Program. Pediatrics May 2017 139 : e20164146. 10.1542/peds.2016-4146

Short courses of oral corticosteroid medication are recommended for treatment of moderate to severe asthma exacerbations. Concern has been raised about OCS overuse. Our objective is to describe rates of OCS dispensing among children with asthma and factors associated with variation in OCS dispensing.

Claims data for children 1 to < 18 years of age with an asthma diagnosis between January 2011 and January 2016 were extracted from the computerized databases of Texas Childrens Health Plan.

Systemic Corticosteroids In Asthma Exacerbations

Asthma: When to use inhaled steroids in 60 seconds

The Cochrane Collaboration maintains numerous ongoing systematic reviews of randomized controlled trials of systemic steroids versus placebo in acute exacerbations of asthma in children and adults. In one Cochrane Review, patients who were treated with short courses of steroids required significantly less care as defined by relapse to additional care within 7 to 10 days , fewer hospitalizations , and less need of -agonist use . In addition, patient symptom scores improved with steroid therapy however, no significant comparisons could be made owing to a lack of standardization in the use and reporting of scores between the studies. The overall incidence of side effects, such as vomiting and headache, was reported as rare, with no significant differences between the groups this might be partly due to the limited information provided in these studies. No significant differences were identified between different routes of administration. The review concludes that a short course of systemic steroids is beneficial in moderate to severe asthma exacerbations. Mild exacerbations can be treated with -agonist therapy and inhaled corticosteroids, with the addition of systemic steroids if a patients symptoms do not improve.8

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For Severe Persistent Asthma

When used as a controller medicine, the daily dose of oral steroids is prescribed based on the following recommended ranges in adults:

  • Prednisone: 5 mg to 60 mg per day
  • Prednisolone: 5 mg to 60 mg per day
  • Methylprednisolone: 4 mg to 50 mg per day
  • Dexamethasone: 0.75 mg to 10 mg per day

The recommended dose in children is calculated at roughly 1 mg/kg per day for prednisone, prednisolone, and methylprednisolone. Dexamethasone is calculated at 0.3 mg/kg per day.

It is always best for those with severe persistent asthma to start with the lowest possible dose of oral corticosteroids and to only increase the dose if symptoms are not effectively controlled. An overdose of these medications can lead to vomiting, weakness, seizures, psychosis, and severe heart rhythm disruptions.

Once treatment is started, it can take up to two weeks before the full benefits are felt.

Oral Dexamethasone Vs Oral Prednisone For Children With Acute Asthma Exacerbations: A Systematic Review And Meta

  • 1Department of Pediatrics, Shengli Oilfield Central Hospital, Dongying, China
  • 2Department of Hematology, Shengli Oilfield Central Hospital, Dongying, China

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 and Google scholar databases was carried out till 1st August 2019. Six Randomized controlled trials 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 15 days and 1015 days of follow up . Pooled analysis found no significant difference in relapse rates with 1-day and 2-day dosage of dexamethasone compared to prednisone. Hospital readmission rates after initial discharge were not significantly different between the two drugs . Frequency of vomiting at ED and at home was significantly higher with prednisone as compared to dexamethasone.

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