Steroids are recommended for moderate to severe asthma exacerbations by the National Asthma Education and Prevention Program.1 Emesis of oral prednisolone syrup is not uncommon and may result in hospitalization, a need for intravenous steroids, or suboptimal therapy.2,–4
Researchers from Columbia University compared the clinical efficacy of a single dose of intramuscular dexamethasone sodium phosphate (IM dex) to a five-day course of oral prednisolone for the treatment of children with asthma exacerbations.
Patients aged 18 months to six years were enrolled if they presented with a mild to moderate asthma exacerbation and had a history of at least two prior episodes of respiratory illnesses treated with bronchodilators.
Prior to initial treatment, the severity of symptoms in study children was assessed by a clinical asthma score based on respiratory rate, retractions, and wheezing (score range of 0–9). Patients who had scores between 3 and 7 were randomized to receive either IM dex (0.6 mg/kg, maximum 15 mg) or oral prednisolone suspension (2 mg/kg, maximum 50 mg). Patients who had emesis of prednisolone within 30 minutes of administration were redosed. Patients who had emesis after the second dose of prednisolone were given intravenous (IV) methylprednisolone (2 mg/kg). Patients receiving IM dex received no further steroid therapy; those randomized to receive oral prednisolone were prescribed an additional four doses to be given daily.
Data on study children who required admission to the hospital were not included in the final analysis. A repeat clinical asthma score was obtained in study children 96 to 120 hours after enrollment.
The primary study outcome was change in the clinical asthma score between enrollment and the four-day follow-up evaluation in children discharged from the emergency department. Data for secondary outcomes were obtained through structured interviews with the parents of study patients at four and 14 days after enrollment.
There were 88 patients randomized to the IM dex group and 93 to the oral prednisolone group. The demographics of the two groups were similar. Initial mean clinical asthma scores were 4.6 in IM dex patients and 4.4 in prednisolone patients. Admission rates were similar with 17/88 (19%) IM dex patients requiring admission compared to 19/93 (20%) oral prednisolone patients. Emesis occurred in six (6%) prednisolone patients; three of these children had a second episode of emesis and were given IV methylprednisolone.
Guardians of patients in the prednisolone group reported 94% compliance with administration of at least three doses. At the four-day follow-up assessment, there was no difference in the change in mean clinical asthma score between the IM dex group and oral prednisolone group. There were also no clinically meaningful differences in secondary outcome measures including respiratory signs at four-day follow-up, admission rates within 14 days, or unplanned physician visits within 14 days. Emesis occurred at least one time in 9/69 (13%) of...