Systemic Steroids for the Treatment of Acute Asthma

Abstract

Despite over 50 years of clinical experience, many uncertainties persist with respect to the onset of action, doseresponse characteristics, duration of treatment, and optimal route of administration of systemic steroids when used in the treatment of severe acute asthma. Studies show that treating severe acute asthma with systemic corticosteroids within 1 hour of presentation to the emergency department lowers hospitalization rates and improves pulmonary function. The onset of action may be seen in as little as 2 hours in studies using peak flow, but may be delayed as much as 6 hours in studies using forced expiratory volume in 1 second as the pulmonary function outcome measure. A clear dose-response is seen at doses below 40 mg per day of methylprednisolone or equivalent; however, there is limited evidence for any added efficacy when doses above 60 to 80 mg per day are administered. There is no clear benefit of intravenous systemic steroids over oral steroids for treatment of severe acute asthma. High-dose inhaled corticosteroids may have a potential role, but further studies are needed to confirm efficacy. There is good evidence that a short course of oral systemic steroids for 3 to 7 days after initial steroid therapy prevents rebound asthma symptoms; no steroid taper is required if the patient was receiving inhaled steroids. Intramuscular steroids are at least equally effective and may be useful in patients who poorly adhere to their medication regimens; however, they are associated with more side effects than oral therapy.

Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations

“…A Cochrane review (six trials; 374 patients) found that the use of corticosteroids was associated with significant reduction in the number of relapses, hospitalization rates and use of SABAs. [ 348 349 ] In another review of 12 studies involving 863 patients, administration of corticosteroids within 1 h of presentation was associated with a significant reduction in hospital admission rates with a number needed to treat of eight, with no increase in adverse effects. [ 350 ] In a meta-analysis of six trials (344 adult patients) comparing the dose and route of administration of corticosteroids in hospitalized patients, it was found that low-dose systemic steroids (≤80 mg/day of methylprednisolone or ≤400 mg/day of hydrocortisone or <100 mg/day of prednisolone) were equally effective when compared to either medium-dose (>80 mg ≤360 mg/day of methylprednisolone or > 400 ≤1800 mg/day of hydrocortisone, or >100mg ≤450 mg/day of prednisolone) or high-dose (>360/day of methylprednisolone or >1800 mg/day of hydrocortisone or 450 mg/day of prednisolone) corticosteroids.…”

Turkish Thoracic Society asthma management and prevention guideline: key points

“…Further bronchodilation can be achieved with combination of ipratropium with salbutamol (224)(225)(226). Systemic glucocorticosteroids should be administered orally or intravenously as they accelerate the resolution of exacerbation (0.5 mg/kg for 7-10 days) (1,34,50,(227)(228)(229).…”

Acute Severe Asthma

“…However, despite extensive clinical experience with these agents, there remains considerable uncertainty as to the onset of action, dose-response characteristics, duration of treatment, optimal route of administration and the patient population likely to require or respond to corticosteroids in emergency situations when used for the treatment of acute severe asthma. [78] The treatment of acute severe asthma with corticosteroids within 1 hour of presentation to the emergency department lowers hospitalization rates and improves pulmonary function. [79] Their onset of action may be seen in as little as 2 hours in studies measuring peak flow, but may be delayed as much as 6 hours in studies using FEV 1 as the pulmonary function outcome measure.…”