Is a 2-day course of oral dexamethasone more effective than 5 days of oral prednisone in improving symptoms and preventing relapse in children with acute asthma?

BACKGROUND: Dexamethasone, a long-acting corticosteroid successfully used in acute treatment of croup, may prevent more relapses than prednisone in asthmatic children.

POPULATION STUDIED: The authors studied known asthmatic persons (defined by 2 or more episodes of wheezing treated with b-agonists with or without steroids) aged 2 to 18 years presenting to a children’s health hospital emergency department (ED) with an acute asthma exacerbation requiring more than 1 albuterol nebulizer treatment. Nursing staff assessed asthma severity based on either peak expired flow rates or a validated asthma severity scoring system. Children were excluded for recent oral corticosteroid treatment, history of intubation, recent varicella exposure, stridor, possible foreign body, and certain chronic diseases. During an 11-month period, 628 subjects enrolled, of whom 533 (85%) completed the study. Two thirds were men, 84% were black, and the average age was between 6 and 7 years. Fifty-six percent of the children were classified as moderate asthma severity at presentation; the remainder was evenly distributed between mild and severe.

STUDY DESIGN AND VALIDITY: This controlled trial assigned children to receive oral prednisone (2 mg/kg, maximum 60 mg, n= 261) on odd days and dexamethasone (0.6 mg/kg, maximum 16 mg, n=272) on even days. The first dose was given in the ED; the prednisone group was sent home with a prescription for 4 daily doses, the dexamethasone group was given a prepackaged dose for the following day. Children who vomited 2 doses of steroid or were directly admitted to the hospital from the ED were dropped from the study.This was a quasirandomized study, in that children were placed on one drug on even days and the other steroid on odd days. As a result, the allocation to the specific treatment groups was not concealed. Although patient severity is unlikely to have varied systematically on even and odd days, a large potential exists for a bias to be introduced into this study. Nurses who believed one treatment was superior to another could have systematically altered enrollment of children into the study based on the treatment of that day. These 2 issues—lack of randomization and concealed allocation—could invalidate the results of the study. The majority of subjects were black. Asthma prevalence, morbidity, and mortality are higher among black children, especially those in urban settings.¹ There is also some evidence of physiologic predisposition in this population, namely, higher serum immunoglobulin E levels and increased airway responsiveness.² However, no literature suggests that there is a difference in asthma treatment response between black children and children of other races or ethnicities.

OUTCOMES MEASURED: The primary outcome was rate of relapse within 10 days of discharge from the ED. Secondary outcomes were rate of hospitalization, frequency of vomiting, medication compliance, persistence of symptoms, and work or school days missed.

RESULTS: By evaluating the children who completed the study, the authors determined that the relapse rates were similar between the 2 groups, 7.4% in the dexamethasone group and 6.9% in the prednisone group (P = NS). Intention-to-treat analysis also found no difference between treatments. The number of admissions after relapse and the prevalence of persistent symptoms was also similar between the 2 groups. More children in the prednisone group missed 2 or more school days (P =.05), and more parents in this group reported not giving the medication at home (P =.004).