Current Treatment Of Acute Asthma
Acute asthma exacerbations are defined as episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness, or some combination of these symptoms. Most recently, an expert group formed by the National Institutes of Health agreed to define acute asthma as a worsening of asthma requiring the use of systemic corticosteroids to prevent a serious outcome. Acute exacerbation of asthma symptoms is a common complication of the disease. The frequency in which exacerbations happen vary widely depending on the severity of disease, the degree of control with prophylactic medications, and exposure to triggers. In a multicenter study from the US, the admission rate of all comers to the emergency department with acute asthma was 23%. On the other hand, a European study showed that only about 7% of all patients with acute asthma exacerbation required hospitalization. We have a similar experience in Saudi Arabia where about 8% of all asthmatics with acute exacerbation are hospitalized, but if we look at only the severe group the rate goes up to 40%. These epidemiological data underscores the importance of effective treatment of asthma exacerbations and their prevention.
Corticosteroids For Severe Presentation
Corticosteroid therapy is typically reserved for patients refractory to standard first-line bronchodilators and with impending respiratory failure.2 EMS providers are often left with a choice of dexamethasone or methylprednisolone without any evidence-based consensus on which drug is most beneficial.
To date, no trials have directly compared dexamethasone vs. methylprednisolone in the adult population. However, in pediatric patients, a recent meta-analysis purports the utility of dexamethasone as a viable alternative to prednisone/prednisolone therapy in patients experiencing an acute asthma exacerbation.3 Currently its unknown which patients may benefit most from intravenous administration of corticosteroids. Thus, in the absence of any contraindications, patients who present in severe exacerbations should receive systemic corticosteroids.4
The pathophysiologic basis for the use of corticosteroids in COPD/asthma exacerbations resides in their ability to reduce airway inflammation. The non-genomic anti-inflammatory mechanisms exerted by corticosteroids work rapidly making them an attractive option in severe exacerbations. Corticosteroids also have genomic mechanisms due to their lipophilic nature and ability to alter transcription of inflammatory mediators, however these arent of concern to EMS providers due to their delayed onset of action .
What Are The Possible Side Effects Of Methylprednisolone
Side effects are possible with any medication, and you should always be aware of possible side effects before starting any new medication. The most common side effects associated with taking methylprednisolone include: headache, nausea and vomiting, weight gain, restlessness, mild swelling in the ankles, feet, or hands, acne or other skin problems, increased thirst, infection, high blood pressure, and depression. These side effects typically are mild and go away on their own. For severe side effects that dont go away, contact your doctor. This is not a complete list of side effects.5
More severe side effects are possible, and you should contact your doctor immediately if you experience any of these and are taking methylprednisolone:6
- Cold or infection that lasts a long time
- Black or tarry stool
These are not all the possible side effects of methylprednisolone. Talk to your doctor about what to expect or if you experience any changes that concern you during treatment with methylprednisolone.
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How Does Methylprednisolone Work
Methylprednisolone is an anti-inflammatory medication that works by decreasing your bodys immune response.1 Methylprednisolone is a corticosteroid that is similar to a natural hormone made by your bodys adrenal glands. When your body does not make enough of this hormone on its own, methylprednisolone can be used to treat the symptoms, commonly swelling and inflammation, that are caused by the lack of this natural hormone.6
Introduction And Evolution Of Corticosteroids In The Management Of Asthma: Historical Background
Shortly after the discovery of the structure of adrenal steroid hormones, Hench et al. examined using cortisone to treat arthritis in 1949. The effect was remarkable and that work won the Nobel Prize the next year. It also started a series of trials of corticosteroids in various inflammatory conditions. The first use of corticosteroid to treat acute asthma exacerbation was in 1956. Development of corticosteroids that have less mineralocorticoid activity, like prednisone, and later those that have no mineralocorticoid activity, like dexamethasone, made corticosteroids more attractive therapies to use in asthma. In 1972, Clark showed for the 1st time that inhaled beclomethasone was effective in the management of asthma with less adverse effects than systemic steroids. Numerous reports came afterwards describing the efficacy of oral prednisone and prednisolone , IV methylprednisolone and ICS such as triamcinolone, budesonide, and fluticasone in the management of asthma. These effects are mediated through various genomic and nongenomic mechanisms. Table 2 shows some common systemic corticosteroids and their relative potency.
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How Well It Works
A review of research shows that treatment with systemic corticosteroids during an asthma attack reduced hospital admissions and the frequency of relapse in adults.footnote 1
A review of research on treatments for asthma in children found that systemic corticosteroids during an asthma attack shortened the duration of hospital visits for asthma attacks for children.footnote 2
In children, corticosteroid pills reduce the severity and length of an asthma attack. But for the pills to stop an asthma attack, it is important to give them at the first sign of symptoms.footnote 3
Are Prednisone And Other Oral Steroids Safe For Asthma
While a two-week course or “short burst” of oral steroids like prednisone is relatively safe, itâs important to avoid steroids on a long-term basis as there are potential serious side effects. Taking supplemental calcium may help to prevent osteoporosis or thinning of the bones, which is one of the side effects of long-term steroid use.
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Intramuscular Versus Oral Corticosteroids For Acute Asthma
We examined the effectiveness of an injection of corticosteroids compared to corticosteroids taken by mouth to improve outcomes among patients who presented to an emergency department or similar acute care setting with acute asthma.
Asthma attacks result from airway passages to the lungs becoming constricted due to inflammation, resulting in wheezing, coughing and difficulty breathing. People experiencing asthma attacks often go to emergency departments. Corticosteroids, which are powerful anti-inflammatory agents, are the treatment cornerstone of asthma exacerbations, and have been shown to be effective in improving lung function and reducing hospitalisations in patients with asthma. At discharge, patients are commonly provided with corticosteroids to reduce the chance of returning to the emergency department due to worsening asthma symptoms. Corticosteroids may be provided via a single injection under the skin into the muscle or as tablets to take home, and it is currently unclear which regimen of corticosteroids is more effective at improving outcomes for patients following discharge from the emergency department.
We conducted our most recent search in March 2018.
Study funding sources
Quality of the evidence
Participants receiving IM corticosteroids or oral corticosteroids both reported decreases in peak expiratory flow , similar symptom persistence , and 24-hour beta-agonist use .
What Are Some Other Side Effects Of Solu
All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:
- Upset stomach or throwing up.
- Trouble sleeping.
- Sweating a lot.
These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.
You may report side effects to the FDA at 1-800-332-1088. You may also report side effects at https://www.fda.gov/medwatch.
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What Iv Methylprednisolone Dose Is Optimal For Acute Asthma
Darrell Hulisz, PharmD
|Response from Darrell Hulisz, PharmD Associate Professor, Case Western Reserve University School of Medicine Clinical Specialist in Family Medicine, University Hospitals, Case Medical Center, Cleveland, Ohio|
Several pharmacotherapeutic options are available to treat acute asthma exacerbations. These include high-dose, multiple-dosed, inhaled beta-2 adrenergic agonists , inhaled anticholinergic agents , fluids, and oxygen. Systemic corticosteroids are indicated in acute asthma exacerbations to decrease airway inflammation or for patients who fail to respond promptly and completely to conventional therapy. Patients who require emergency department stabilization and/or subsequent hospitalization with a peak expiratory flow rate of < 25% of predicted should receive intravenous corticosteroids.
It is conventional to use IV corticosteroids in this setting over inhaled corticosteroids however, some investigators have shown similar results with oral steroids compared with IV steroids in adults. Clinical results also were not different in a pediatric population given IV methylprednisolone or oral prednisone at equipotent doses.
For The Treatment Of Status Asthmaticus
Intravenous, Intramuscular, Intraosseal dosage
40 to 80 mg/day IV or IM in 1 to 2 divided doses until peak expiratory flow is 70% of predicted or personal best is recommended by the NAEPP.
Infants, Children, and Adolescents
2 mg/kg IV, IM, or IO load , then 0.5 mg/kg/dose IV every 6 hours or 1 mg/kg/dose IV every 12 hours . Some experts recommend 0.5 to 1 mg/kg/dose IV every 4 to 6 hours.
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Emergency Department Clinical Pathway Forevaluation/treatment Of Children With Asthma
- Consider Dexamethasone tablet
- Dexamethasone tablet
- Albuterol MDI q20min x 3, prn RT assess
- Dexamethasone tablet Alternative: IM dex/ IV solumedrol
- Unineb: Albuterol x3 + ipratropium
|500 mcg over 1 hr in unineb or 250 mcg q20 min x 2||4|
|1000 mcg over 1 hr in unineb or 500 mcg q20 min x 2||6|
|1000 mcg over 1 hr in unineb or 500 mcg q20 min x 2||8|
|2 mg/kg p.o./IV, MAX 60 mg|
|Dexamethasone: Mild-moderate flare, repeat in 24-48 hours, crush tablet with cherry syrup, juice, or yogurt|
|50 mg/kg, MAX 2 g Give with Normal saline bolus, 20ml/kg q15 min VS, observe in ED 60 min prior to transfer to inpatient floor|
Intermittent dose: Repeat as needed every 15-30 minutes for a maximum of 3 doses total:
Precautions While Using Solumedrol
It is very important that your doctor check you or your child’s progress at regular visits to make sure this medicine is working properly and to decide if you should continue to receive it. Blood or urine tests may be needed to check for unwanted effects.
Using this medicine while you are pregnant can harm your unborn baby. Use an effective form of birth control to keep from getting pregnant. If you think you have become pregnant while receiving this medicine, tell your doctor right away.
If you are receiving this medicine for a long time, the skin at the injection site may become slightly depressed or wrinkled. Talk to your doctor if you notice any of these changes at the injection site: depressed or indented skin, or pain, redness, or sloughing of the skin.
This medicine may cause an allergic reaction called anaphylaxis, which can be life-threatening and requires immediate medical attention. Call your doctor right away if you have a rash, itching, trouble breathing, trouble swallowing, or any swelling of your hands, face, or mouth while you are receiving this medicine.
If you are receiving this medicine for a long time, tell your doctor about any extra stress or anxiety in your life, including other health concerns and emotional stress. Your dose of this medicine might need to be changed for a short time while you have extra stress.
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Proper Use Of Solumedrol
This section provides information on the proper use of a number of products that contain methylprednisolone. It may not be specific to SoluMEDROL. Please read with care.
A nurse or other trained health professional will give you this medicine. It may be given through a needle placed into one of your veins, as a shot into a muscle or joint, or as a shot into a lesion on your skin.
Your doctor may give you a few doses of this medicine until your condition improves, and then switch you to an oral medicine that works the same way. If you have any concerns about this, talk to your doctor.
How Is This Medicine Best Taken
Use Solu-Medrol as ordered by your doctor. Read all information given to you. Follow all instructions closely.
- It is given as a shot.
- If you have been taking Solu-Medrol for many weeks, talk with your doctor before stopping. You may want to slowly stop Solu-Medrol .
- Have your eye pressure checked if you are on Solu-Medrol for a long time. Talk with your doctor.
- Have a bone density test as you have been told by your doctor. Talk with your doctor.
- You may need to lower how much salt is in your diet and take extra potassium. Talk with your doctor.
What do I do if I miss a dose?
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Serious Neurologic Adverse Reactions With Epidural Administration
Serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids. Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke. These serious neurologic events have been reported with and without use of fluoroscopy. The safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use.
Things To Know About Methylprednisolone
As with any medication, the benefit of taking it should outweigh the risks. And for some asthma patients, methylprednisolone is not recommended. If you are allergic to methylprednisolone or any of its ingredients, tell your doctor. Your doctor should also know if you have any allergies to foods, dyes, preservatives, or animals.5
For some groups, there is not enough scientific information to conclude if there is a high risk associated with taking methylprednisolone. The safety of methylprednisolone has not been established in children or elderly patients. Also, the safety is unknown for infants of breastfeeding mothers who take methylprednisolone.5
Also always tell your doctor what other medications you are taking if you are prescribed methylprednisolone. Some medications cannot be taken at the same time as methylprednisolone. Use of methylprednisolone with Desmopressin and live vaccines is not recommended. In addition, some medications taken with methylprednisolone may increase your risk of side effects. It is not recommended to take cyclosporine or ketoconazole with methylprednisolone because these drugs can cause the amount of methylprednisolone in your body to be increased, which increases the likelihood for side effects.5
There are other drugs that may also interact with methylprednisolone, so be sure to share all of your medications with your doctor.
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Systemic Steroids For Treating Asthma
Oral prednisone and dexamethasone are the currently recommended systemic steroids for moderate to severe asthma exacerbations. Formulations such as hydrocortisone and methylprednisolone can be given parenterally. Studies have found these routes to be equally effective, with the oral route being less painful and invasive.10,11 Prednisone is given for 5 days at a dose of 1 to 2 mg/kg daily . Dexamethasone can be given for 1 to 5 days at a dose ranging from 0.3 to 0.6 mg/kg daily. Dexamethasone is a long-acting glucocorticoid with a half-life of 36 to 72 hours, and is 6 times more potent than prednisone. Prednisone is shorter acting, with a half-life of 18 to 36 hours.12
Recognizing the debate in choice and dose of corticosteroids, the Cochrane Database generated a protocol to investigate this issue in hospitalized patients with asthma, but a review has not yet been published.13
Appropriate Selection Of Corticosteroids In Treating Asthma And Copd
Youre dispatched to the scene of a residential facility for a patient with difficulty breathing. You and your partner arrive to find an elderly male on his living room couch in clear respiratory distress as indicated by tripod positioning with accessory muscle use, pursed lip breathing, and paradoxical chest wall/abdominal movements .
Initial impression of your patient reveals he has difficulty speaking due to his increased respiratory effort and explains that recently hes unable to catch his breath. He says he recently ran out of his home DuoNeb treatments.
Further questioning reveals hes a chronic smoker and has a confirmed diagnosis of chronic obstructive pulmonary disease and asthma, both of which are pharmacologically managed without home oxygen administration.
When asked supplemental questions regarding allergies and current symptoms, the patient appears to be confused, which is consistent with his progressively declining mental status.
Initial vitals are significant for elevated blood pressure , tachycardia , marked tachypnea and an oxygen saturation of 88% on room air .
Physical exam reveals wheezing/coarse rhonchi on auscultation with prolonged expiration, notable clubbing of extremities, barreled chest , diffusely decreased breath sounds and hyperresonance on percussion. End-tidal carbon dioxide capnography is appropriately applied revealing a shark-fin appearance further confirming your suspicion for COPD/asthma exacerbation.
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What Do I Need To Tell My Doctor Before I Take Solu
For all uses of Solu-Medrol :
- If you have an allergy to methylprednisolone or any other part of Solu-Medrol .
- If you are allergic to Solu-Medrol any part of Solu-Medrol or any other drugs, foods, or substances. Tell your doctor about the allergy and what signs you had.
- If you have any of these health problems: A fungal infection or malaria infection in the brain.
- If you have a herpes infection of the eye.
- If you have nerve problems in the eye.
- If you have idiopathic thrombocytopenic purpura .
This is not a list of all drugs or health problems that interact with Solu-Medrol .
Tell your doctor and pharmacist about all of your drugs and health problems. You must check to make sure that it is safe for you to take Solu-Medrol with all of your drugs and health problems. Do not start, stop, or change the dose of any drug without checking with your doctor.