Efficacy Endpoints: Asthma exacerbation relapse
Harm Endpoints: Tachycardia, tremor
Narrative: The Cochrane review that assessed the efficacy of inhaled corticosteroids (ICS) ICS at discharge for patients with acute asthma exacerbations actually performed two separate analyses: one for the addition of ICS to standard corticosteroids (CS) therapy versus CS therapy alone and the other for ICS alone versus CS therapy alone at discharge. In the first analysis, there were 3 included trials (N = 909), all of patients with moderate-severe asthma, as determined by airflow measurements. The control groups received 5-7 days of prednisone group while the additional ICS therapy was for 20-24 days. There was no difference in relapse rates at 7-10 days and 20-24 days between the two groups.
In the second analysis, there were 7 trials (N = 684), 4 pediatric and 3 adult, with severe asthmatics excluded. In all studies, high dose ICS were used and nearly all control group patients received a tapered dose of CS. In 5 studies, the duration of both therapies was 7 days, in one study it was for 16 days and another, the ICS group was treated for 24 days while the control group only eight. At 7-10 days, there was no difference in relapse rates between the 2 treatment groups.
Caveats: *In the first analysis, there was a trend towards a decrease in relapse rates with the addition of ICS to CS; however, this difference did not reach statistical significance. In the second analysis, only 4 of the 7 trials reported relapse rate data. The authors on the Cochrane Review express concern about the possibility of Type II error in these data. Accordingly, interpreting these data to suggest that ICS alone are equivalent to CS in preventing relapse in acute asthma exacerbation patients being discharged is not supported at this time. For harm, the only aggregated data we were able to find appears to suggest that there may be a small, clinically difficult-to-detect negative impact of systemic steroids on growth in children due to intermittent steroids in asthma, while there was no detectable impact of inhaled corticosteroids. These effects were from small, heterogeneous studies and should be considered preliminary.1
Author: Ashley Shreves, MD
Published/Updated: January 10, 2010
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