Single-dose regimens are of greatest interest to health care providers in ambulatory care settings because of the potential to improve compliance, as has been documented in studies of a variety of other single-dose therapies.Three studies reported the use of a single dose of intramuscular (IM) dexamethasone. One study of 533 children reported 10-day relapse rates of 7.4% with dexamethasone versus 6.9% with prednisone (Single-dose dexamethasone regimens also have been compared with 3- or 5-day use of prednisone. What dose? Click below to contact us or find us on Twitter. Kim et al reported an 18% vomiting rate for generic prednisolone versus a rate of 5% for the better-tasting prednisolone sodium phosphate oral solution formulation in 188 children.Direct studies of dexamethasone for asthma support its tolerability. inhaled ipratropium. The most common dosing regimen is 1-2mg/kg (max dose 60mg) PO once-to-twice daily for 3-5 days. No vomiting was reported after an oral dexamethasone dose in a study of 61 children.Growing evidence suggests that single-dose dexamethasone (oral or IM) for mild-to-moderate pediatric asthma exacerbation is as effective as multiday prednisone regimens, with better taste and improved compliance. Further RCTs with comparison to existing literature are necessary to definitively determine which dosing regimen is most appropriate. Two options are roughly equivalent: (a) Stacked nebs: 2.5-5 mg via nebulizer Q20 minutes back-to-back. Of note, they didn’t look at the difference in injection site pain between the PO and IM routes, but I would be confident that PO prednisone would be favorable to IM dexamethasone there.Very recently (May of 2016) the Cochran Library updated their meta-analysis titled “Different Oral Corticosteroid Regimens for Acute Asthma.” They analyzed the same questions with largely the same set of studies with two other data sources that are only now available. It seems very expected that an IM injection would cause less emesis than a PO medication. Also, the paper highlights the secondary outcome that dexamethasone treated patients vomited less. Klig et alIn these studies of mild-to-moderate pediatric asthma, IM dexamethasone appears to be as effective as 3 to 5 days of oral prednisone or prednisolone.Intramuscular dexamethasone injections are painful and can be difficult to administer, so oral administration is a preferred route, especially owing to a suggested 80% bioavailability.One study followed up with 110 children at 5 days after randomization to either a single dose of oral dexamethasone (0.6 mg/kg, maximum 18 mg) or oral prednisolone (1 mg/kg per dose, maximum 30 mg) twice daily for 5 days. Having options is nice.Instructor, Division of Emergency Medicine, Department of Pediatrics, Feinberg School of Medicine, Northwestern UniversityNUEM Blog is a resident educational site devoted to enhancing emergency medicine education through online, asynchronous learning. which demonstrated that the dexamethasone group was more likely to require repeat doses of corticosteroids. Ann Emerg Med . The main limitation of the current literature is that there is a disagreement between studies regarding the ideal dose. Dexamethasone has demonstrated no statistically significant difference in relapse rates (defined as return visit to ED, clinic, or unanticipated hospitalization in one meta-analyses of 6 RCTs) and has demonstrated a lower frequency of emesis. high dose inhaled albuterol. The current mainstay of treatment is beta-agonist and corticosteroid administration. Patients should be started on high-dose albuterol. 2016;68(5):608–613. Dexamethasone’s half-life is double that of each medication (12-36 hours for prednisone/prednisolone vs 36-72 hours for dexamethasone) and thus, a single dose may provide an equipotent therapy compared to multiple doses of either other steroid. Most of the studies also excluded patients with a high fever, other signs of infection such as active herpes/varicella, tuberculosis exposure and critically ill asthma exacerbations (in which case intravenous corticosteroids is preferred). Multiple studies have also demonstrated noncompliance with prednisone and some literature suggests that parents would prefer the one time dexamethasone to prednisone.
Larger-scale studies, including those to determine the safest and most effective dose, are still needed in order to build confidence in a single-dose approach for children with mild-to-moderate asthma.Do you have questions about the effects of drugs, chemicals, radiation, or infections in children? Dexamethasone’s half-life is double that of each medication (12-36 hours for prednisone/prednisolone vs 36-72 hours for dexamethasone) and thus, a single dose may provide an equipotent therapy compared to multiple doses of either other steroid. But when it comes to writing the order for the medication, the devil is in the details. Perhaps, the real take away message should be that any difference between different corticosteroids is likely negligible. Some exacerbations warrant admission for inpatient care, but many can be managed effectively on an outpatient basis with a combination of avoiding environmental triggers, inhaled β-agonists, a short course of oral steroids, and close follow-up.Traditionally, a short course of steroids (prednisone or prednisolone for 5 days) has been recommended.Two pediatric studies have compared the use of 2 doses of oral dexamethasone (day 1 and day 2) with 5 days of prednisone (or prednisolone). “My daughter is a terror taking medications and spits out every dose I give her at home.” Let’s try dexamethasone. They have looked at thousands of patients, and any clinically important difference should have been determined by this point. The question still remains is 0.3 mg/kg or 0.6 mg/kg the ideal dose and whether a single, or two dose, regimen is needed. Given the potential for multiple doses per day for multiple days, some clinicians have questioned whether an equivalent dose of dexamethasone is just as efficacious. Addition of ipratropium to initial therapy (e.g.