Single-dose dexamethasone or 5-day prednisone?

In acute asthmatic attacks, the 5-day regimen appears to be slightly better but single-dose administration may improve adherence

Acute asthmatic attack (AAA) is one of the more common cases seen at the emergency room. Many asthma exacerbations are managed with a five-day course of prednisone. Some physicians prefer oral dexamethasone which has similar bioavailability as oral prednisone but has the advantage of a longer half-life.

Rehrer MW whether a single dose of oral dexamethasone plus four days of placebo is not inferior to five days of oral prednisone in treatment of adults with mild to moderate asthma exacerbations to prevent relapse. This was defined as an unscheduled return visit for additional treatment for persistent or worsening asthma within 14 days. (Ann Emerg Med 2016 Apr 22)

Single-dose dexamethasone or 5-day prednisone

The investigators randomized adult cases with AAA (aged 18 to 55 years) brought to the ER to receive either a single dose of 12 mg of oral dexamethasone with four days of placebo or a five-day course of oral prednisone 60 mg/day. The patients were followed up by phone interview to check for relapses at two weeks.

A total of 173 dexamethasone and 203 prednisone subjects completed the study regimens and telephone follow-up. The authors reported that the dexamethasone group, by a small margin, surpassed the preset difference of 8 percent between groups for noninferiority in relapse rates within 14 days (12.1 percent versus 9.8 percent; CI–4.1 percent to 8.6 percent). Subjects in the two groups had similar rates of hospitalization for their relapse visit. Adverse effect rates were generally the same in the two groups.

The authors concluded: “A single dose of oral dexamethasone did not demonstrate noninferiority to prednisone for five days by a very small margin for treatment of adults with mild to moderate asthma exacerbations. Enhanced compliance and convenience may support the use of dexamethasone regardless.”

In his commentary in NEJM Journal Watch, Daniel J. Pallin, MD, MPH noted that the trial was limited by its very high rate of loss to follow-up. “Nevertheless, its results are consistent with prior research, and therefore I conclude that a single dose of 12-mg dexamethasone by mouth seems a reasonable alternative to a five-day course of prednisone for adults with acute asthma exacerbations,” he wrote. However, he recommends a larger trial with better follow-up to validate this recommendation. With a report from NEJM Journal Watch

June 2016 Health and Lifestyle

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