Anti-inflammatory Treatment after Discharge Home from the Emergency Department in Adults with Acute Asthma

Abstract

Airway inflammation from respiratory infections or exposure to allergens, irritants, or both leads to increased airflow obstruction and respiratory symptoms in patients with acute asthma. Antiinflammatory therapy with systemic corticosteroids (CSs) is therefore a cornerstone of the management of patients with acute asthma, particularly those presenting to the emergency department (ED) (1, 2). After initial management in the ED, most patients improve sufficiently to be discharged home with instructions to complete a short course of daily oral corticosteroids (OCSs) and short-acting inhaled bronchodilators as needed for symptom relief. Unfortunately, up to one third of patients who initially respond to therapy relapse within the first 3 to 4 weeks after ED discharge (e.g., require treatment escalation, urgent care or ED visits, or hospitalizations for asthma) (3, 4). The propensity of many patients to relapse after ED discharge has led to a number of randomized clinical trials evaluating alternative outpatient antiinflammatory treatment strategies in this population, including the use of inhaled corticosteroids (ICSs), intramuscular corticosteroids (IMCSs), and noncorticosteroid anti-inflammatory regimens. The objective of this systematic review is to synthesize the results of randomized clinical trials in adults with acute asthma, comparing alternative outpatient anti-inflammatory treatment strategies to reduce the risk of relapse after discharge home from the ED. More specifically, this systematic review examined the following anti-inflammatory treatment options in adults after ED discharge: (1) IMCSs versus OCSs, (2) ICSs versus OCSs, (3) combination of ICSs plus OCSs versus OCSs alone, and (4) noncorticosteroid anti-inflammatory agents (macrolide antibiotics and leukotriene modifiers) in addition to systemic corticosteroids. This report updates previously published systematic reviews in acute asthma (5–7) with subsequently published studies and provides a single document summarizing this body of literature for easy use by clinicians.