Dexamethasone vs Prednisone for Inpatient Asthma

Abstract

Source: Hemani SA, Glover B, Ball S, et al. Dexamethasone versus prednisone in children hospitalized for acute asthma exacerbations. Hosp Pediatr. 2021 Nov;11(11):1263-1272; doi:10.1542/hpeds.2020-004788Investigators from Emory University, Atlanta, GA, conducted a retrospective study to compare length of stay (LOS) in children hospitalized for asthma exacerbations and treated with dexamethasone (DEX) or prednisone/prednisolone. For the study, they identified patients, 3-21 years old, hospitalized at 1 of 3 hospitals with a primary discharge diagnosis of asthma exacerbation or status asthmaticus between 2013 and 2017 using ICD-9 and ICD-10 codes. Children initially admitted to an ICU were excluded, and only those who received PRED or DEX monotherapy prior to or during their hospitalization were included. The medical records of study participants were reviewed and information on demographics, other medications used during the asthma exacerbation, timing of initial dose of PRED or DEX, and LOS abstracted. Asthma acuity at ED presentation was assessed in study children using a validated clinical respiratory score (CRS). The primary outcome was LOS, and secondary outcomes were transfer to an ICU during hospitalization and ED visit or re-hospitalization within 10 days of discharge. Study patients were categorized as beginning corticosteroids prior to hospitalization or after admission, and these 2 groups were analyzed separately. Regression analyses were used to compare outcomes between those treated with PRED or DEX in each group. Covariates in the regression models included age, sex, race, ethnicity, insurance type, hospital, CRS, and use of other asthma medications during the exacerbation.There were 1,410 children included in the analysis; 981 (69.6%) were treated with DEX, and 429 (30.4%) received PRED. Of 961 patients started on corticosteroids after admission, 826 received DEX and 135 PRED, and among 449 children started on treatment before admission, 155 and 294, respectively, received DEX or PRED. For patients who began corticosteroids after hospitalization, and after controlling for covariates, LOS was significantly shorter in those who received DEX than in children treated with PRED (mean LOS 24.43 hours; 95% CI, 21.13, 28.25, and 29.38 hours; 95% CI, 24.15, 35.73, respectively; P = 0.03). Conversely, when treatment was begun prior to admission there was no significant difference in LOS between those treated with DEX or PRED (mean LOS, 26.72 hours; 95% CI, 21.62, 33.03; and 25.20 hours; 95% CI, 20.49, 30.99, respectively; P = 0.45). Overall, rates of transfer to ICU and hospital readmission were 0% to 2%, with no significant differences between patients treated with DEX or PRED. Among the group of children for whom corticosteroids were started after hospitalization, 18 (2.2%) of those receiving DEX had an ED visit within 10 days of hospital discharge vs 0 of those receiving PRED (P = 0.09).The authors conclude that in children hospitalized with an asthma exacerbation who had corticosteroid treatment initiated after admission, those treated with DEX had a shorter LOS than those receiving PRED.Dr Winer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.As DEX becomes increasingly utilized for mild-to-moderate asthma exacerbations in pediatric emergency departments,1 questions arise regarding the initiation and continuation of DEX vs PRED for patients admitted for asthma exacerbations not requiring an ICU. The results of the present study illustrate that, in a multisite hospital system, DEX has become the predominant (86%) corticosteroid initiated after hospital arrival. Patients who received DEX after hospital arrival had approximately 20% shorter LOS, even after adjustment for measured potential confounders.However, association does not imply correlation. As a retrospective cohort study, the authors of the present study are unable to determine if giving DEX as compared to PRED shortens LOS. “Indication bias,” any factor, clinical or otherwise, affects the decision to utilize 1 treatment over another and is not accounted for in the current analysis. Adjustment can minimize the effect of measured factors, but a randomized controlled trial is necessary to establish causality.It is important to also acknowledge possible implicit bias based on the idea of “reliability” needed to complete a 5-day course of PRED.1 In the present study, patients with government insurance and Black patients were approximately half as likely to receive PRED as those with private insurance and white patients, respectively. Recognition and investigation of the reasons for differences in practice are necessary to ensure equitable treatment of patients with asthma.Pediatric patients admitted with asthma exacerbation outside of the ICU who receive DEX after hospital arrival have a shorter LOS than those who receive PRED. (See AAP Grand Rounds. 2022;47[1]:10.)2With nearly 10 million children in the US affected by asthma and 80,000 hospitalized annually,3 it is readily apparent why the therapy of asthma continues to pepper these pages.2 Future investigators comparing DEX and PRED need to examine prior home use of corticosteroids and include children with severe asthma exacerbations.