University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• In children with moderate to severe acute asthma exacerbation does using oral corticosteroids when compared to intravenous corticosteroids lead to higher rates of hospitalization?

Clinical Bottom Lines

1. No significant differences between oral and IV corticosteroids in rates of hospitalization or rates of return to the ED within 48 hours.

Summary of Key Evidence

1. Randomized controlled trial involving 49 pediatric patients presenting with moderate to severe asthma exacerbation were recruited as part of a convenience sample upon presentation to a large, urban pediatric ED.
   
2. Inclusion criteria: Patients were 18 months to 18 years of age; the presenting event was at least the third episode of wheezing; they had moderate to severe exacerbation of asthma as defined by Pulmonary Index Score between 6 and 11 for patients 18 months to 6 years, or FEV1 < 60% for patients 7 years to 18 years of age
   
3. Exclusion Criteria: Oral or inhaled steroids in the preceding two weeks; concomitant respiratory (e.g. CF), cardiac (e.g. complex congenital heart disease), or neurologic (e.g. moderate to severe CP) disease.
   
4. All patients received nebulized albuterol, 0.15 mg/kg, every 20 minutes for one hour and 0.3 mg/kg every hour for three more doses. In addition, IV theophylline was given as part of a standard protocol for acute asthma exacerbation.
   
5. Methylprednisolone was administered 30 minutes after the start of the study.
   
6. To maintain blinding, all patients received either placebo oral syrup or IV solution.
   
7. The main outcome of the study was hospital admissions after the 4-hour study period.
   
8. After 4 hours of therapy, admission rates were not different between the oral and IV groups (48% vs 50% respectively, P=.88). Pulmonary function was significantly better in those discharged home.
   
9. Validity of the study is enhanced by randomized, double-blinded, placebo-controlled design.
   
10. The small sample size makes the study prone to a Type I error: the possibility of demonstrating no difference when one actually exists. The study is not adequately powered to demonstrate no statistically significant difference between groups.
    
11. Differences in baseline characteristics between groups (oxygen saturation higher in the oral groups 96% Vs 93.4%, p=0.001 and those in the IV group were less likely to have used steroids in the past and had fewer previous episodes of asthma exacerbation) may compromise the validity of the results.
    
12. The use of theophylline may limit the generalizability of the results.
    

Additional Comments

• Mechanism of action of corticosteroids in the treatment of asthma is not entirely clear, but includes interference with arachidonic acid metabolism and synthesis of leukotrienes; prevention of activation and migration of inflammatory cells, and increased responsiveness of B-receptors of airway smooth muscle.
  
• AAP and University of Michigan Clinical Guidelines recommend the use of systemic corticosteroids in the treatment of moderate to severe asthma exacerbation, but acknowledge the controversy surrounding the route of administration.
  

Citation

1. Barnett PLJ, et al. Intravenous versus oral corticosteroids in the management of acute asthma in children. Annals of Emergency Medicine 1997; 29:217-.
   
2. Cada DJ. Drug Facts and Comparison. St. Louis, MO: Drug Facts and Comparison, 2002.
   
3. Lacy CF. Drug Information Handbook, 9th Edition. Lexicomp Publishing: Hudson, OH, 2001.
   
4. Margo K. Oral versus IV steroids for asthma. The Journal of Family Practice 1997; 44(5):441.
   
5. National Asthma Education Report, expert panel report. Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health, 1991:NIH publication no. 91-3042A, 1991.
   
6. Amy Skyles, pharmacy student, University of Michigan Drug Information Services.

CAT Author: Gen Stewart, MD

CAT Appraisers: Eugene Golding, MD

Date appraised: August 5, 2002