SP9 Moving away from traditional asthma exacerbation therapies – single dose dexamethasone
Authors: Andrew Lilley 
Published: January 2018

Introduction

Prednisolone has been the mainstay of treatment for acute exacerbation of asthma for some time. Course length is usually between 3–5 days depending on severity and patient history. However, treatment is not without its issues. Preparations suitable for use by young children such as 5 mg soluble tablets have poor palatability and are very expensive. In addition to this, several patients at the trust have been noted to have poor compliance with treatment once discharged from ED. Many feel better after the first dose and because parents ‘don’t want their children to be on unnecessary steroids’ the course of treatment is not completed. This can lead to re-attendance due to reoccurrence of symptoms and additional steroid treatment.

With the introduction of liquid preparations such as the orange flavoured 10 mg/ml solution from focus pharmaceuticals palatability has improved as well as a slightly lower price. However, the issue of poor compliance still remains.

Method

A group of health care professionals reviewed evidence relating to the management of acute asthma over the course of one day. The purpose being that no one was to bring their personal opinions to the event and should only consider the evidence being presented. One of the main points to be considered was steroid use in exacerbations. Evidence was presented that a single dose of dexamethasone at a dose of 0.6 mg/kg (max 16 mg) was non inferior to 3 days of prednisolone at an age appropriate dose.1 Some children, in particular those who are admitted to hospital with more severe exacerbations, may require a further dose 24 hours later (making it equivalent to 5 days of treatment). The group voted unanimously in favour of the change and the change was approved by the trust CGEG committee. It was agreed that after 6 months the change would be audited to see how effective the change has been.

Results

Patient lists were obtained from the trust informatics system and initial review of data was performed by junior pharmacist. Unfortunately data from the system was poor and generated only small numbers. Further review of patient notes was done by author. It showed that in 6 months 146 patients attended accident and emergency receiving dexamethasone as treatment for acute exacerbation of asthma. In these children, 42 were admitted to the hospital with duration of stay between 1–7 days. Of these children only 12 received a second dose of dexamethasone based on consultant review of need.

In those receiving a single dose their re-attendance rate was the same as that of those who received prednisolone in the preceding 6 months (8% Dex vs 9% Pred).

Conclusion

A single dose of dexamethasone was shown to be non-inferior to comparable dose of prednisolone in the trusts patients. The switch removed the issue of non-completion of treatment as well as reducing the cost associated with treatment with a predicted £24 000 saving for the ED predicted in the first 12 months of use. Further work is needed to see how this treatment affects adrenal function long term.

Reference

Keeney RL, et al. Dexamethasone for acute asthma exacerbations in children: A meta-analysis. Paediatrics Mar 2014;133(3).