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Communications to the Editor |

Corticosteroids in the Emergency Treatment of Acute Severe Asthma FREE TO VIEW

T. K. Lim, MD
Author and Funding Information

National University HospitalSingapore

Correspondence to: T. K. Lim, MD, Department of Medicine, National University Hospital, Lower Kent Ridge Rd, Singapore 119074; e-mail: mdclimtk@nus.edu.sg



Chest. 2000;117(5):1526-1527. doi:10.1378/chest.117.5.1526-a
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To the Editor:

I read with interest the review by Drs. Rodrigo and Rodrigo (August 1999)1on the role of corticosteroids in the emergency treatment of acute asthma. In a meta-analysis, they found no evidence for either rapid (< 6 h) improvement of pulmonary function or reduction in hospital admission rates. From the pooled results of six studies, they calculated a 32% reduction in admission rates in patients treated with IV corticosteroids, and they estimated that the average number of patients treated to avoid one hospitalization would be 12.5 (95% confidence interval [CI], 7.1 to 50). However, their survey did not include the randomized controlled study by Lin et al,2 who administered IV methylprednisolone (125 mg) to adult asthmatics who had predicted peak expiratory flow rates of< 50% after initial albuterol aerosol treatment. Lin et al2reported significant improvement in pulmonary function 60 min and 120 min following IV treatment with corticosteroids. This improvement was in addition to the effect of inhaled ipratropium bromide and albuterol, which was administered to all subjects. They also noted a nonsignificant reduction in the admission rate of 31%. In an accompanying editorial, Gallagher3 incorporated the results of the study by Lin et al2 in another meta-analysis, and estimated that the number of patients needed to be treated with IV corticosteroids to avoid one admission was seven (95% CI, 4 to 16).

At our institution, the average cost of hospitalization is $1,000 (for an adult patient with an average stay of 3.8 days).4 By contrast, the cost of IV methylprednisolone, 125 mg, is $19. On average, then, 53 second-line treatments with methylprednisolone in the emergency department are comparable in cost to a single admission for asthma. This ratio is higher than the break points estimated by both Rodrigo and Rodrigo (50:1)1 and Gallagher (16:1).3

A similar comparison may be made with inhaled corticosteroids, which are the second-line agents actually recommended by Rodrigo and Rodrigo.1 This is based on their own study, which showed the efficacy of inhaled flusinolide as primary treatment in acute severe asthma.5 Inhaled flunisolide is not available to us in Singapore, but 6 mg of inhaled fluticasone (which has higher potency than flunisolide) would cost $13. While the physiologic improvement seems better and the reduction in admission rates appear higher with inhaled rather than IV corticosteroids, the studies by Lin et al2 and by Rodrigo and Rodrigo5 are not directly comparable, since only the first study evaluated steroids in second-line treatment.

I submit that, contrary to the view by Rodrigo and Rodrigo, the evidence favors the use of IV rather than inhaled corticosteroids in the supplementary treatment of patients with acute severe asthma in the emergency department.

References

Rodrigo, G, Rodrigo, C (1999) Corticosteroids in the emergency department therapy of acute adult asthma: an evidence-based evaluation.Chest116,285-295
 
Lin, RY, Pesola, GR, Bakalchuk, L, et al Rapid improvement of peak flow in asthmatic patients treated with parentral methylprednisolone in the emergency department: a randomized controlled study.Ann Emerg Med1999;33,487-494
 
Gallagher, EJ Reconciliation of conflicting evidence [editorial].Ann Emerg Med1999;33,561-564
 
Chew, FT, Goh, DYT, Lee, BW The economic cost of asthma in Singapore.Aust NZ J1999;29,228-233
 
Rodrigo, G, Rodrigo, C Inhaled flunisolide for acute severe asthma.Am J Respir Crit Care Med1998;157,698-703
 

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Tables

References

Rodrigo, G, Rodrigo, C (1999) Corticosteroids in the emergency department therapy of acute adult asthma: an evidence-based evaluation.Chest116,285-295
 
Lin, RY, Pesola, GR, Bakalchuk, L, et al Rapid improvement of peak flow in asthmatic patients treated with parentral methylprednisolone in the emergency department: a randomized controlled study.Ann Emerg Med1999;33,487-494
 
Gallagher, EJ Reconciliation of conflicting evidence [editorial].Ann Emerg Med1999;33,561-564
 
Chew, FT, Goh, DYT, Lee, BW The economic cost of asthma in Singapore.Aust NZ J1999;29,228-233
 
Rodrigo, G, Rodrigo, C Inhaled flunisolide for acute severe asthma.Am J Respir Crit Care Med1998;157,698-703
 
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