Question

• For children with persistent asthma who develop an acute exacerbation, does increasing the dose of their controller inhaled steroid reduce the severity of their symptoms?

Clinical Bottom Lines

1. Doubling of inhaled steroid dose for a three day period during an acute exacerbation of persistent asthma did not result in statistically significant differences in morning and evening peak expiratory flow rates (PEFR).
2. Additionally, there were no significant differences in asthma symptom scores, spirometric measurements, parental satisfaction, and adverse outcomes between baseline and increased inhaled steroid groups.
   

Summary of Key Evidence

1. This is a randomized, double-blinded, placebo controlled trial in 28 children aged 6-14 with mild to moderate persistent asthma who received either double their inhaled steroid dose or baseline inhaled steroid dose plus placebo inhaler for the first three days of their asthma exacerbation.¹
2. Exclusion criteria included concurrent oral steroid use, long acting ß-agonist use, cromlyn use, or history of ICU admission, recent inpatient stay, or change in inhaled steroid dose in the previous 2 months to study entry.
3. After stratification for age and sex, the children were randomized to receive one of two possible treatment sequences for serial exacerbations, placebo than steroid, or steroid then placebo.
4. The main outcomes of the study included morning and evening PEF, asthma symptom scores, spirometric measurements, parental satisfaction, and adverse outcomes.
5. The methods of the article were valid - patients were randomly allocated, all patients were accounted for at the study end, the researchers were blinded, and study groups were treated equally.
6. No statistical significant difference (p < 0.05) was detected in any outcome measure of the study between the increased and baseline inhaled steroids groups (18 total paired asthma exacerbations).

Additional Comments

• There are three studies examining the effectiveness of inhaled steroid with placebo for acute exacerbations in children previously not on inhaled steroids. Overall, the administration of high dose inhaled steroids did not decrease the need for oral corticosteroids or hospitalization.²
• In a study by Connett and Lenney, there was a significant decrease in reported wheeze, but no difference in cough, bronchodilator use, or symptom duration.
• Wilson and Silverman found asthma symptom scores to be significantly lower in the inhaled steroid group.
• Svedmyr reported significantly higher PEFRs (104% vs 96% predicted), but no difference in symptomatology.
• There are several studies in children and adults demonstrating similar efficacy between inhaled steroids and oral steroids. However, the dose of inhaled steroids was high and the effect may be secondary to systemic absorption.²
• The side effects of inhaled steroids are minimal. A study by the Childhood Asthma Management Program Group studied the effects of inhaled steroids and found a mean decrease in growth of 1.1 cm at the end of the study, but no significant differences in final projected growth, bone density, or Tanner stage.³
  

Citation

1. Garrett J, Williams S, Wong C, Holdaway D. Treatment of acute asthmatic exacerbations with an increased dose of inhaled steoid. Arch Dis Child 1998; 79: 12-17.
2. Hendeles L, Sherman J. Are inhaled corticosteroids effective for acute exacervatoins of asthma in children. J Pediatr 2003; 142:S26-S33.
3. Childhood Asthma Management Program Research Group. Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med 2000; 343: 1054-63.

CAT Author: Jim Connelly, MD

CAT Appraisers: John Frohna, MD

Date appraised: May 25, 2005