Intramuscular Corticosteroids Research Articles

Anti-CD-20 Therapy in Refractory Adult Still’s Disease

Adult Still’s disease is a relatively rare form of rheumatoid arthritis with systemic inflammatory features. The prevalence is around 1.5 cases per 100,000 - 1000,000. In the current case we display a 30-year-old male patient with refractory adult still’s disease who suffered recurrent attacks of fever 39.5°C, arthritis in proximal interphalangeal joints (PIPs), wrists, tempromandibular joints (TMJs), knees and ankles, stitching chest pain, dyspnea, erythematous rash over the trunk, sore throat, weight loss (15 Kilograms in 4 months). The patients’ disease remained uncontrolled despite of synthetic disease modifying anti-rheumatic drugs and repeated intramuscular corticosteroid injections. Laboratory workup revealed erythrocyte sedimentation rate (ESR) of 95, C-reactive protein (CRP) of 100 mg/L, hemoglobin 10.5 gm%, leukocytosis 12,000/microlitre, mild elevation of liver function tests and dyslipidemia. Serology revealed negative rheumatoid factor, anti-nuclear antibody titre of 1:80, elevated serum ferritin 4000 micrograms/litre. The patient was started on rituximab (375 mg/m2), prednisolone 20 mg/day and selective Cox-2 inhibitor. Follow up for over three months following the completion of his pulse therapy, revealed no relapse of fever or fatigue, with morning stiffness of 5 - 10 minutes, VAS of 3, DAS28 of 3.8, HAQDI of 0.62, ESR 23, CRP 4.9, Hb 12.5 gm%, leucocytic count 9000/microlitre, the dose of prednisolone was successfully reduced to a dose of 5 mg/day orally. Conclusion: Anti-CD20 therapy successfully controlled systemic and articular refractory disease with sustained efficacy over a follow up period of up to 24 weeks.

Effectiveness of intramuscular corticosteroid injection versus placebo injection in patients with hip osteoarthritis: design of a randomized double-blinded controlled trial

BackgroundRecent international guidelines recommend intra-articular corticosteroid injections for patients with hip osteoarthritis who have moderate to severe pain and do not respond satisfactorily to oral analgesic/anti-inflammatory agents. Of the five available randomized controlled trials, four showed positive effects with respect to pain reduction. However, intra-articular injection in the hip is complex because the joint is adjacent to important neurovascular structures and cannot be palpated. Therefore fluoroscopic or ultrasound guidance is needed.The systemic effect of corticosteroids has been studied in patients with impingement shoulder pain. Gluteal corticosteroid injection was almost as effective as ultrasound-guided subacromial corticosteroid injection. Such a clinically relevant effect of a systemic corticosteroid injection offers a less complex alternative for treatment of patients with hip osteoarthritis not responsive to oral pain medication.Methods/DesignThis is a double-blinded, randomized controlled trial. A total of 135 patients (aged > 40 years) with hip osteoarthritis and persistent pain despite oral analgesics visiting a general practitioner or orthopaedic surgeon will be included. They will be randomized to a gluteal intramuscular corticosteroid injection or a gluteal intramuscular placebo (saline) injection. The randomization will be stratified for setting (general practitioner and outpatient clinics of department of orthopaedics). Treatment effect will be evaluated by questionnaires at 2, 4, 6, and 12 weeks follow-up and a physical examination at 12 weeks. Primary outcome is severity of hip pain reported by the patients at 2-week follow-up. Statistical analyses will be based on the intention-to-treat principle.DiscussionThis study will evaluate the effectiveness of an intramuscular corticosteroid injection on pain in patients with hip osteoarthritis. Patient recruitment has started.Trial RegistrationThis trial is registered in the Dutch Trial Registry: number NTR2966.

Narrowband ultraviolet B phototherapy for alopecia areata

Although narrowband ultraviolet B (NB UVB) phototherapy is a well-established treatment in many dermatosis, there is little evidence of efficacy of this method for alopecia areata (AA) treatment in the literature. We undertook a retrospective review of the 25 AA patients treated with NB UVB. Intramuscular triamcinolone acetonide injections per month were used as concomitant treatment in some patients who did not have any contraindication. Eight patients (32%) received monthly intramuscular corticosteroid injections. Four (22.2%) and two (20%) patients achieved excellent response in extensive patchy hair loss patients and entire scalp hair loss patients, respectively. Four of six patients who achieved excellent response also received monthly intramuscular corticosteroid injections. When patients receiving systemic corticosteroid injections were compared with patients given only NB UVB with respect to the treatment responses, a statistically significant difference was seen in patients who achieved excellent response. NB UVB is not an effective treatment with only 20% excellent treatment responses in patients with severe AA, most of whom were also treated with systemic corticosteroids.

Tissue engineered strategies for skeletal muscle injury.

Skeletal muscle injuries are common in athletes, occurring with direct and indirect mechanisms and marked residual effects, such as severe long-term pain and physical disability. Current therapy consists of conservative management including RICE protocol (rest, ice, compression and elevation), nonsteroidal anti-inflammatory drugs, and intramuscular corticosteroids. However, current management of muscle injuries often does not provide optimal restoration to preinjury status. New biological therapies, such as injection of platelet-rich plasma and stem-cell-based therapy, are appealing. Although some studies support PRP application in muscle-injury management, reasons for concern persist, and further research is required for a standardized and safe use of PRP in clinical practice. The role of stem cells needs to be confirmed, as studies are still limited and inconsistent. Further research is needed to identify mechanisms involved in muscle regeneration and in survival, proliferation, and differentiation of stem cells.

PCV36 High Dose and Long-Term Safety of Systemic Corticosteroids in the Treatment of Polymylagia Rheumatica and Vasculitis: A Systematic Review

To review the evidence base for the safety of high dose and long-term usage of systemic corticosteroids (CSs). Selection of studies: population-based studies involving patients with polymyalgia rheumatica or vasculitis treated with systemic CSs and reporting the incidence of diabetes, hypertension, cataract, osteoporosis or cardiovascular events. Search strategy: A systematic literature review was conducted in Medline, Medline-in-process, Embase, and the Cochrane Library up to January 2011, with very broad search terms in order to limit the risk of missing relevant studies. Data synthesis: “Key studies” were identified as assessing comparisons relevant to our study question (CSs vs. no use of CSs and/or assessment of CSs at different doses) and reporting at least one outcome of interest by treatment group. Results were summarized separately for key studies and other studies. Out of 3671 citations initially identified for screening 76 publications were selected. Few studies were identified as key: only 3 reported the incidence of diabetes, hypertension or cardio-vascular events, four studies documented the development of cataract and seven reported outcomes related to osteoporosis. Based on these studies, outcomes such as cataract and osteoporosis presented a higher rate of incidence for both indications within the CSs treatment groups, and tended to be less common when the treatment arm combined intravenous or intramuscular CSs with oral CSs than with oral CSs alone. No significant association was found for the other outcomes of interest. The magnitude of the CSs effect on the outcomes of interest varied greatly between studies. Although CSs are a cornerstone of treating polymyalgia rheumatica and vasculitis, the evidence base for their safety profile is poor, subject to a high level of heterogeneity, and the findings for the different outcomes were not always consistent across studies, demonstrating the need for further research in this area.

Iatrogenic Cushing syndrome after a single intramuscular corticosteroid injection and concomitant protease inhibitor therapy

Iatrogenic Cushing syndrome after a single intramuscular corticosteroid injection and concomitant protease inhibitor therapy

Palmoplantar nonpustular psoriasiform dermatitis in a rhesus macaque

A case of psoriasiform dermatitis in an adult male rhesus macaque is reported. Appearing spontaneously, the condition presented the clinical and histopathological features of human palmoplantar nonpustular psoriasis. The animal developed multiple scaly plaques on his palms and soles, as well as nail hyperkeratosis and widening of the nail root. Microscopically, the skin lesions showed epidermal hyperkeratosis with multifocal parakeratosis, neutrophil microabscesses in the stratum corneum, a loss of granule cell layer under the microabscesses, acanthosis, and elongation of the rete ridges; the superficial dermis showed a dense inflammatory infiltrate containing lymphocytes, macrophages and neutrophils, as well as dilated and tortuous blood vessels. The lesions improved for 15 days after intramuscular corticosteroid depot therapy and worsened slightly afterwards. Later, a spontaneous, progressive remission coincided with the beginning of spring and lasted until the end of summer; the skin lesions practically disappeared during this period, and the nails looked nearly normal. During the next autumn and winter only nail hyperkeratosis was present. Serum analyses showed hyperproteinaemia and hyperglobulinaemia during the outbreak phase and normal values during remission. The clinical and histopathological features of this case, as well as its evolution, are compared with the three other reported cases of psoriasiform skin lesions in nonhuman primates. To the authors' knowledge, this is the first report of a definite palmoplantar nonpustular psoriasiform dermatitis in a rhesus macaque.

High-Dose Treatment With Vitamin A Analogues and Risk of Fractures

To study fracture risk associated with use of systemic vitamin A analogue (isotretinoin and acitretin) treatment. Case-control study. Nationwide registry. A total of 124 655 patients with fractures (cases) and 373 962 age- and sex-matched controls. Main Outcome Measure Incidence of fractures in patients with and without exposure to systemic vitamin A analogues. Confounder control was performed for social variables, contacts with hospitals and general practitioners, alcoholism, and a number of other variables known to potentially affect fracture risk, including use of systemic, intramuscular, and topical corticosteroids and antiepileptic drugs and comorbid conditions. No trend in risk of any fracture or of hip, forearm, or spine fractures was present with increasing doses or durations of treatment with vitamin A analogues. Subdividing vitamin A analogues into isotretinoin and acitretin did not change the results. Risk of fracture is not associated with vitamin A analogue treatment.

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

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.

Anti-Inflammatory Treatment After Discharge Home from the Emergency Department in Adults with Acute Asthma

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.

Anti-inflammatory treatment after discharge home from the emergency department in adults with acute asthma

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.

The effect of systemic corticosteroid treatment on the immunolocalisation of Notch-1, Delta, CD105 and CD166 in rat articular cartilage

We studied the immunolocalisation of the stem cell-specific markers Notch-1, Delta, CD105 and CD166 in rat articular cartilage and analysed the effect of systemic corticosteroid treatment on the patterns of distribution of cells labelling for these markers. Female Wistar rats were separated randomly into two groups: the control group (n=8) was injected with isotonic salt solution and the corticosteroid group (n=8) was injected with 10 mg/kg intramuscular corticosteroid (methylprednisolone) once a week for a period of 8 weeks. Femoral head specimens from each group were obtained at the end of the treatment and processed for routine histological and immunohistochemical examinations. Quantitative data were obtained by H-SCORE and statistical evaluations were performed. The immunolocalisation of all markers was more apparent in the superficial zone and decreased through the deeper zones in all groups. However, the intensity of labelling was much less obvious in the group treated with corticosteroid compared to control. H-SCORE analysis confirmed that in the group treated with corticosteroid, the intensity of Notch-1, Delta, CD105 and CD166 labelling had decreased significantly compared to control (p<0.05). In conclusion, based on the immunolocalisation of stem cell-specific markers Notch-1, Delta, CD105 and CD166, the data suggest that the stem cells may continue to exist in adult rat articular cartilage. It was also observed that systemic corticosteroid treatment may effect the immunolabelling intensity of these markers, suggesting that corticosteroid treatment may reduce the function and the regenerative capacity of these cells in articular cartilage.

Intramuscular Fetal Corticosteroid Therapy: Short-Term Effects on the Fetus

Objective: The aim of the study was to assess the short-term effects of direct intramuscular (i.m.) corticosteroid therapy on fetal biophysical profile, baseline fetal heart rate and the nonstress test, which indicate the degree of fetal hypoxia. Method: We evaluated the effect of direct i.m. fetal single-dose dexamethasone (4 mg/kg) on the fetal biophysical profile 2 h before and 2–4 h after corticosteroid therapy in 41 fetuses in the 32nd week of gestation at risk of preterm delivery. Risk factors for preterm delivery included pregnancy-induced hypertension and preeclampsia. Result: There was a statistically significant difference between fetal breathing movements before and after corticosteroid therapy (p = 0.019; 95% confidence interval for difference –11.75, –1.12). No significant changes were observed between baseline fetal heart rate before and after corticosteroid therapy (p = 0.99; 95% confidence interval for difference –4.81, +4.81), biophysical profile before and after fetal corticosteroid therapy, p = 0.235 as well as the nonstress test before and after therapy (p = 0.564). Conclusion: Direct corticosteroid i.m. fetal therapy results in increasing profound short-term fetal breathing movements. There are no changes in baseline fetal heart rate, biophysical profile score, and nonstress test.

Letters to the Editor

Letters to the Editor

How to prevent relapse after acute exacerbation of asthma?

It is well known that most patients survive an acute ex-acerbation of asthma. This observation is in keeping with the natural tendency of acute asthma to resolve, providing treat-ment is prompt. Actually, for the majority of patients with an asthma exacerbation, management in the community or emergency department (ED) is adequate. Nonetheless, pa-tients released from the ED after an acute exacerbation can relapse after discharge. The systematic review of randomized controlled trials published by Rowe et al. [1] strongly supports the use of oral or intramuscular (IM) corticosteroids (CSs) for treatment of outpatients released from the acute care setting with an exacerbation of asthma. Apparently, a short course of CSs following assessment for an asthma exacerbation sig-nificantly reduces the number of relapses to additional care, hospitalizations and use of short-acting

Corticosteroids for preventing relapse following acute exacerbations of asthma

Acute asthma is responsible for many emergency department (ED) visits annually. Between 12 to 16% will relapse to require additional interventions within two weeks of ED discharge. Treatment of acute asthma is based on rapid reversal of bronchospasm and reducing airway inflammation. To determine the benefit of corticosteroids (oral, intramuscular, or intravenous) for the treatment of asthmatic patients discharged from an acute care setting (i.e. usually the emergency department) after assessment and treatment of an acute asthmatic exacerbation. We searched the Cochrane Airways Group Specialised Register and reference lists of articles. In addition, authors of all included studies were contacted to locate unpublished studies. The most recent search was run in October 2006. Randomized controlled trials comparing two types of corticosteroids (oral, intra-muscular, or inhaled) with placebo for outpatient treatment of asthmatic exacerbations in adults or children. Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Six trials involving 374 people were included. One study used intramuscular corticosteroids, five studies used oral corticosteroids. The review was split into two reviews and although the latest search yielded no additional placebo controlled trials an additional IM study was included. Significantly fewer patients in the corticosteroid group relapsed to receive additional care in the first week (Relative risk (RR) 0.38; 95% confidence interval (CI) 0.2 to 0.74). This favourable effect was maintained over the first 21 days (RR 0.47; 95% CI 0.25 to 0.89) and there were fewer subsequent hospitalizations (RR 0.35; 95% CI 0.13 to 0.95). Patients receiving corticosteroids had less need for beta(2)-agonists (mean difference (MD) -3.3 activations/day; 95% CI -5.6 to -1.0). Changes in pulmonary function tests (SMD 0.045; 95% CI -0.47 to 0.56) and side effects (SMD 0.03; 95% CI -0.38 to 0.44) in the first 7 to 10 days, while rarely reported, showed no significant differences between the treatment groups. Statistically significant heterogeneity was identified for the side effect results; all other outcomes were homogeneous. From these results, as few as ten patients need to be treated to prevent relapse to additional care after an exacerbation of asthma. A short course of corticosteroids following assessment for an asthma exacerbation significantly reduces the number of relapses to additional care, hospitalizations and use of short-acting beta(2)-agonist without an apparent increase in side effects. Intramuscular and oral corticosteroids are both effective.

The influence of direct intramuscular corticosteroid therapy on parameters of venous circulation in hypoxaemic fetuses

The influence of glucocorticosteroid therapy on foetal lung maturation is evident but little is known about its effects on parameters of foetal venous circulation. The aim of the study was to assess the influence of direct intramuscular (i.m.) foetal corticosteroid therapy (CST) on parameters of foetal venous circulation which indicates a degree of foetal hypoxia. The prospective study was conducted at the Institute of Gynaecology and Obstetrics during 2001. We evaluated the influence of direct i.m. foetal single dose dexamethasone (2 mg/ kg estimated foetal weight by sonographic examination) on foetal ductus venosus (DV) and vena cava inferior (VCI) velocities in 49 foetuses 24 hours before and after therapy. There is positive correlation with the statistical significance in systolic/diastolic ratio (S/D) in DV before and after the corticotherapy r = 0.366; p = 0.018. Reverse flow during contraction of the right atrium in DV was found in 55.6% of foetuses after CST. Reverse flow during the contraction of the right atrium in VCI was found in 3 foetuses before CST and in 4 foetuses after CST. We found positive correlation without statistical significance between the vena cava pre-load indices before and after CST (r = 0.127; p = 0.428). There is positive correlation with the statistical significance between systolic flow in VCI before and after CST (r = 0.478; p = 0.002). Corticosteroid therapy influences parameters of foetal venous circulation. Its influence depends on duration of foetal hypoxia. The parameters of foetal venous circulation can be a predictor of the perinatal outcome.

Prenatal Corticosteroids

After completing this article, readers should be able to: 1. Describe the standard of care for prenatal corticosteroids for women in preterm labor prior to 34 weeks’ gestation. 2. Describe the effects of prenatal corticosteroids on the fetus. 3. List the preferred corticosteroid for prenatal treatments. 4. Explain the recommendation regarding not using repetitive courses of prenatal corticosteroids. Prenatal glucocorticoids are standard of care for women at high risk of preterm delivery prior to 34 weeks’ gestation because randomized, controlled trials and extensive meta-analyses demonstrate decreased death and improved outcomes, primarily related to less respiratory distress syndrome (RDS) and a decreased incidence of intraventricular hemorrhages (IVH) (Fig. 1). (1) However, it is worth remembering that the benefits of prenatal corticosteroids initially were demonstrated in 1972, and most of the trials were completed before 1985. Most infants in the trials were delivered after 28 weeks’ gestation and in the presurfactant era, when mortality rates for infants whose birthweights were less than 1 kg were high and when obstetric management differed from current practice. Maternal corticosteroid therapy is validated practice, but care strategies proven to be effective may lose effectiveness as other aspects of care change and the target population most likely to benefit changes. This review asks a series of questions to frame the overriding question of how antenatal corticosteroids should be used in 2006. Figure 1. Meta-analysis of randomized controlled trials of prenatal corticosteroids. Adapted from Crowley. (1) The current recommendations come from the 1994 National Institutes of Health (NIH) Consensus Conference and were reinforced by a second NIH Consensus Conference in 2000. (2) The key points from the guidelines are: 1. The benefits of prenatal corticosteroids outweigh any risks that have been identified. The benefits include decreased death and decreased incidence of RDS and IVH. 2. All fetuses at 24 to 34 weeks’ gestation are candidates …

Bilateral localized lipoatrophy secondary to a single intramuscular corticosteroid injection

A 15-year-old boy developed two, almost symmetric, asymptomatic, depressed plaques, localized to both buttocks after receiving a single intramuscular corticosteroid injection in his right buttock for treatment of lumbar pain. He suffered from asthma since early childhood, and had been repeatedly treated with corticosteroid injections for many years as a young child. A skin biopsy from both lesions was performed, showing a decrease in the number and size of adipocytes. We describe a case of acquired localized lipoatrophy with a particular bilateral distribution secondary to a single intramuscular corticosteroid injection.

The assessment and management of croup

The treatment of croup has changed considerably over the last 25 years with the liberalisation of the use of systemic corticosteroids for mild to moderate croup. The administration of corticosteroids in croup has reduced the severity of the condition, dramatically reduced the need for endotracheal intubation, shortened the duration of intubation, reduced the length of hospital stay, reduced the need for hospital admission and reduced daycare/preschool absenteeism and improved sleep in milder cases. Despite studies showing the efficacy of nebulised and intramuscular corticosteroids, the use of oral corticosteroids remains the recommended option in most, if not all, cases of croup presenting for medical assessment.