Many aspects of medicine are simply based on momentum and routine. One of those routines, in my anecdotal experience, is the use of 5-day courses of steroids for mild/moderate asthma exacerbations. However, why give multiple doses when one will suffice? Why not dexamethasone?
Unfortunately, this meta-analysis doesn’t really bring any new knowledge into play. These authors attempt to pool the results from all the pediatric randomized trials comparing dexamethasone vs. short-course prednisone for the outpatient management of asthma with exacerbation. No included individual trial showed a relapse rate with dexamethasone significantly worse than prednisone – and, unsurprisingly, the pooled results reflect that same finding. The only recorded adverse effect – vomiting in the ED or at home – was seen less frequently with dexamethasone, although the overall incidence in both arms was minimal.
But, there are only six trials, most of which are fewer than 100 patients. These trials are also a mix of oral and intramuscular, single and multiple dose, and dose ranges from 0.3 mg/kg to 1.7 mg/kg (“max 36 mg”!). There were also methodologic problems with blinding, allocation, and other outcomes issues with each included study.
Based on this low-quality evidence, it would be reasonable to say dexamethasone use is not adequately described in the literature. It would, likewise, be reasonable to go ahead and make use of dexamethasone in this setting, with the recognition of these limitations. Personally, I fall on the dexamethasone side of the argument – for children, as well as adults. When feasible, I use an approximately prednisone-equivalent oral dosing at 0.15 mg/kg up to a maximum dose of 12mg in both populations.
And I would love to see a high-quality trial to settle matter, once and for all.
“Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis”
http://www.ncbi.nlm.nih.gov/pubmed/24515516