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Burden of corticosteroids in children with asthma in primary care: retrospective observational study

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7350.1374 (Published 08 June 2002) Cite this as: BMJ 2002;324:1374

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Oral corticosteroids vs inhaled corticosteroids use in acute moderate to severe asthma - evidence based approach - an Indian experience.

Acute exacerbations of asthma defined as acute episodes of progressively worsening shortness of breath, cough, wheezing, chest tightness or a combination of these symptoms. Treatment of acute exacerbations includes inhaled beta 2 agonist, oxygen along with corticosteroids and anticholinergic drugs.
Acute exacerbations of asthma are an important cause of morbidity, school absenteeism and frequent hospital visits.
Anti-inflammatory property of corticosteroids accounts for their effectiveness in asthma. As there is airway inflammation which cause airway compromise in acute exacerbations, there are proven benefits of steroids in acute asthma in resolving the obstruction of the airways.
Corticosteroids have been used in the treatment of asthma for approximately five decades and their proven benefits in the emergency room in treatment of asthma exacerbations.
Corticosteroids are the first line drug therapies in the management of acute asthma exacerbations. Oral or parenteral corticosteroids have been effective equally but parenteral steroids are preferred for critically ill children.
Short-term use of high-dose steroids usually don’t have significant side effects, but may be associated with hyperglycemia, hypertension and other psychiatric problems.
A Cochrane review demonstrated improved outcomes for children who have received corticosteroids at the earliest in the emergency department. As there is difficulty to decide when steroids should be administered. It has been shown that steroids given for a short duration of 3-7 days in children, improve the symptomatology and reduce the chances of an early relapse.
Guidelines mention use of prednisolone 1-2 mg/kg/dose every 6 h for 24 h then 1-2 mg/kg/day in divided doses every 8-12 hours. The total duration of therapy can be 3-7 days depending upon the response. However 5-day courses of oral corticosteroids have not been shown to be superior to 3-day courses for outpatient management of acute exacerbations in children.In our setup we use 3 days of corticosteroid therapy.
Inhaled corticosteroids are very effective drugs in suppressing airway inflammation.
A Cochrane review did not find a significant reduction in the need for oral corticosteroids in school-aged children.
Intermittent inhaled did show symptomatic improvement and lower likelihood of requiring oral corticosteroids in preschoolers,
Inhaled corticosteroids treatment is generally considered generally safe in children. Inhaled corticosteroids are known to cause local and systemic adverse effects. Inhaled corticosteroids therapy should be started at its lowest effective dose because usually adverse effects are dose-dependent.Inhaled corticosteroids do not offer cure to asthmatic children. But there is proven role for inhaled corticosteroids in asthma exacerbations. There is less evidence to recommend that inhaled corticosteroids can replace systemic corticosteroids in emergency room for acute asthma exacerbations.

In our view as there are studies showing minimal side effects of inhaled corticosteroids which are better than oral corticosteroids in treatment of acute moderate to severe asthma. However, Inhaled medications are only effective if they are used precisely. Inhaled corticosteroids show improved clinical control and better airway responsiveness
Adherence to daily inhaled corticosteroid therapy is most important in control of asthma.
As asthma is not a curable disease but using good hygienic practices and creating awareness with appropriate controlling measures, child with asthma minimize the complications and hospitalizations.

References : 1)Elham Hossny,Nelson Rosario,Bee Wah Lee,Meenu Singh,Dalia El-Ghoneimy,Jian Yi SOH,Peter Le Souef. The use of inhaled corticosteroids in pediatric asthma: update.World Allergy Organization Journal20169:26 DOI: 10.1186/s40413-016-0117-0

2)Edmonds ML, Milan SJ, Camargo Jr CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev. 2012;12, CD002308.

3) Sunil Saharan & Rakesh Lodha & Sushil K. Kabra.Management of Status Asthmaticus in Children.Indian J Pediatr (2010) 77:1417–1423 DOI
10.1007/s12098-010-0189-8

4) Chong J, Haran C, Chauhan BF, Asher I. Intermittent inhaled corticosteroid therapy versus placebo for persistent asthma in children and adults. Cochrane Database Syst Rev. 2015;7, CD011032.

5) Chang AB, Clark R, Sloots TP, et al. . A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalised: a randomised controlled trial. Med J Aust. 2008;189(6):306–310 [PubMed].

6)Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001; (1): CD002178

7) Fanta CH, Rossing TH, McFadden ER. Glucocorticoids in acute asthma: A critical controlled trial. Am J Med 1983; 74: 845-851

Competing interests: No competing interests

20 May 2017
KIRAN RAJ H
Pediatrician
SRINIVAS INSTITUTE OF MEDICAL SCIENCES AND RESEARCH CENTRE
SIMS&RC , MUKKA, MANGALURU, KARNATAKA, INDIA