Oral dexamethasone trumps prednisolone for acute asthma attacks in kids

Oral dexamethasone proved more effective than oral prednisolone for the management of acute exacerbation of mild-to-moderate asthma in children, a study suggests.

“Acute exacerbation of asthma is a common condition leading to emergency visits … [R]epeated asthma attacks have adverse impacts on a child’s lung function trajectory … [and left untreated, it] can be fatal,” the researchers noted. It can also impair quality of life and affect the mental wellbeing of children. [Pediatr Pulmonol 2021;56:42‑48] Thus, asthma attacks should be managed aggressively, preferably during the first hour of presentation, considering that children mostly present late to the hospital. [J Asthma 2021;58:1273‑1277]

Up to a quarter of patients relapse despite prednisolone treatment, and most require admission to manage subsequent exacerbations due to poor compliance potentially owing to the prolonged treatment course and unpleasant taste, as well as the side effects. [J Pediatr 2017;191:190‑196.e1; Pediatr Emerg Care 2007;23:521‑527]

“[Our findings suggest that] oral dexamethasone [may be] a reliable and better option [than] prednisolone due to its faster action and minimal side effects,” they said. This could consequently lead to better compliance and improved clinical outcomes. [Pediatr 2014;133:493‑499]

Compared with children given prednisolone, there were fewer children on dexamethasone who had a 6‑hour stay in the emergency department (ED; 6 percent vs 36 percent; p<0.0001) or were admitted (2 percent vs 10 percent; p=0.032). The researchers attributed this to the faster action of dexamethasone than prednisolone. [J Family Med Prim Care 2022;11:1395-1400]

By day 5, dexamethasone use led to marked improvements in PRAM* score compared with prednisolone (0.08 vs 0.21; p=0.046), as well as in the percentage of participants with reduced PEFR** (1 percent vs 16 percent) and with tachypnoea (1 percent vs 5 percent) and accessory muscles used (0 percent vs 1 percent; p<0.001 for all). The improvements in the latter three parameters were evident by the 4^th hour (11 percent vs 26 percent [PEFR], 17 percent vs 32 percent [tachypnoea], and 8 percent vs 18 percent [accessory muscles used]; p<0.05 for all).

While several trials show vomiting as a main side effect of dexamethasone, [Eur J Hosp Pharm 2020;27:151‑156; J Pediatr 2001;139:20‑26; Clin Pediatr (Phila) 2008;47:817‑823] it was not the case in the current study as there were fewer vomiting/gastritis episodes with dexamethasone than prednisolone (17 percent vs 74 percent; p<0.001). According to the researchers, this could be due to dexamethasone’s better taste compared with prednisolone.

A total of 175 children aged 2–14 years were randomized 1:1 to receive oral dexamethasone 0.3 mg/kg (two doses, 24 hours apart) or oral prednisolone 1 mg/kg (two doses, 12 hours apart for 5 days), along with nebulization.

“[Our findings suggest that] two doses of dexamethasone administered 24 hours apart are more effective and safer than a 5‑day course of prednisolone in children with mild‑to‑moderate asthma exacerbation treated in the [ED], particularly by primary care physicians (PCPs),” said the researchers.

“[These findings] are clinically important and offer strong evidence related to the role of dexamethasone as an important option to prednisolone for managing non-life‑threatening asthma in the [ED],” they continued.

“Early recognition and better understanding of management strategies of acute exacerbation of asthma by PCPs will help to reduce future morbidities in children with bronchial asthma,” they added.

However, the follow-up period was rather short, and other factors such as readmissions and treatment adherence were not evaluated. “These parameters are also important in comparing the effectiveness of dexamethasone and prednisolone in children with asthma,” said the researchers.

More randomized trials are thus warranted to validate the current findings and ascertain the optimal dexamethasone regimen.