Study supports dexamethasone for asthma in ER

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Adults with asthma who were treated with one-dose dexamethasone in the emergency department had only slightly higher relapse than patients who were treated with a 5-day course of prednisone. “Enhanced compliance and convenience may support the use of dexamethasone” is the conclusion of a study.

“Any time we can reduce the role of patient compliance with asthma, we have a chance of improving outcomes,” said lead study author Dr Matthew W Rehrer, of the department of emergency medicine with Kaiser Permanente in Oakland, California. “Dexamethasone allows the emergency physician to administer treatment in one dose and doesn’t rely on the patient to remember to take her pills for four more days after leaving the ER. A single dose of medication eliminates prescription adherence barriers such as forgetfulness, cost and dose omission.”

Adult patients with mild to moderate asthma who came to the emergency department were randomly assigned to one of two groups: a single dose of dexamethasone with 4 days of placebo to be taken at home or a 5-day course of oral prednisone. Relapse was defined as an unscheduled return visit to a health care provider for additional treatment for persistent or worsening asthma within 14 days.

Of patients assigned to the dexamethasone group, 12.1% relapsed. Of patients assigned to the prednisone group, 9.8% relapsed. Rates of hospitalisation were about the same: 3.4% for dexamethasone and 2.9% for prednisone.

“In my personal experience as an emergency physician, I had many asthmatic patients relapsing because they were unable to fill their prednisone prescriptions,” said Rehrer. “For those patients and others like them, I might prefer to administer dexamethasone because it eliminates for them the burden of having to fill the prescription and remember to take it for the next four days. When it comes to patient compliance, convenience counts.”

Abstract
Study objective: Oral dexamethasone demonstrates bioavailability similar to that of oral prednisone but has a longer half-life. We evaluate whether a single dose of oral dexamethasone plus 4 days of placebo is not inferior to 5 days of oral prednisone in treatment of adults with mild to moderate asthma exacerbations to prevent relapse defined as an unscheduled return visit for additional treatment for persistent or worsening asthma within 14 days.
Methods: Adult emergency department patients (aged 18 to 55 years) were randomized to receive either a single dose of 12 mg of oral dexamethasone with 4 days of placebo or a 5-day course of oral prednisone 60 mg a day. Outcomes including relapse were assessed by a follow-up telephone interview at 2 weeks.
Results: One hundred seventy-three dexamethasone and 203 prednisone subjects completed the study regimen and telephone follow-up. The dexamethasone group by a small margin surpassed the preset 8% difference between groups for noninferiority in relapse rates within 14 days (12.1% versus 9.8%; difference 2.3%; 95% confidence interval –4.1% to 8.6%). Subjects in the 2 groups had similar rates of hospitalization for their relapse visit (dexamethasone 3.4% versus prednisone 2.9%; difference 0.5%; 95% confidence interval –4.1% to 3.1%). Adverse effect rates were generally the same in the 2 groups.
Conclusion: A single dose of oral dexamethasone did not demonstrate non-inferiority to prednisone for 5 days by a very small margin for treatment of adults with mild to moderate asthma exacerbations. Enhanced compliance and convenience may support the use of dexamethasone regardless.

American College of Emergency Physicians material
Annals of Emergency Medicine abstract


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