Affiliations: Pittsburgh, PA
Dr. Marik is Professor of Medicine, University of Pittsburgh Medical Center, and Dr. Varon is Associate Professor of Medicine, Baylor College of Medicine.
Correspondence to: Joseph Varon, MD, FCCP, 2219 Dorrington, Houston, TX 77030; e-mail: firstname.lastname@example.org
Asthma is a lung disease that is characterized by the presence of increased responsiveness of the airways to various stimuli, reversible expiratory airflow obstruction, and inflammatory changes in the submucosa of the airways. Over the past decade, it has become increasingly recognized that airways inflammation is a major component of asthma.1–2 Due to their potent anti-inflammatory effects, therapy with systemic corticosteroids (oral, IM, or IV) is recommended in all patients presenting to the emergency department with an acute exacerbation of asthma.3–4 Furthermore, a short course of oral corticosteroids following emergency department discharge significantly reduces the number of relapses and the amount of β-agonist use without an increase in side effects.5
Despite > 40 years of experience with the use of corticosteroids in asthma patients, many issues remain unresolved. The optimal dosing schedule of corticosteroids in patients with acute asthma is an issue of much debate, and a precise dose-response relationship has not been determined.6–10 While the benefit of therapy with both systemic and inhaled corticosteroids for reducing the number of relapses in patients following an acute attack and in patients with chronic asthma is indisputable, the benefit of corticosteroid therapy in patients with acute asthma is less clear. A meta-analysis preformed by Rodrigo and Rodrigo11has suggested that the administration of parenteral corticosteroids in addition to inhaled β2-agonists in patients with acute asthma on their arrival at the emergency department neither improved airflow obstruction nor reduced the need for hospitalization. These authors suggested that the failure of steroids to influence the early course of patients with acute asthma is due to the fact that it may take up to 24 h for the effects of corticosteroids to become evident. However, in a randomized placebo-controlled study,12 these same authors have demonstrated that extremely high doses of inhaled glucocorticoids together with salbutamol in patients with acute asthma who were treated in the emergency department significantly improved pulmonary function when compared to the use of salbutamol alone, with this difference being evident by 90 min. It has been suggested that locally acting (inhaled) corticosteroids may cause local vasoconstriction and thereby decrease edema formation and plasma exudation.13
In this issue of CHEST, Edmonds and coinvestigators (see page 1798) present a meta-analysis that indicates that there is some evidence that therapy with high-dose inhaled corticosteroids (beclomethasone dipropionate, ≥ 2,000 μg or equivalent per day) may replace therapy with oral corticosteroids following the emergency department discharge of patients who have been treated for an acute asthma exacerbation. However, the confidence intervals for the primary end points were wide, and the authors caution that equivalence cannot be claimed.
Is there any reason to abandon the standard practice of administering a short course of oral corticosteroids after discharge from the emergency department to patients who have experienced an acute exacerbation of asthma? The meta-analysis by Edmonds and coworkers provides no compelling evidence to change this practice. Oral corticosteroids in a dose equivalent of 40 mg prednisone per day are effective, cheap, and safe. This dose does not cause significant hypothalamic-pituitary-adrenal suppression when used for < 7 to 10 days. What role then do inhaled corticosteroids have in the management of patients with acute asthma? Rowe and colleagues14 have demonstrated that the addition of an inhaled corticosteroid (budesonide, 1,600 μg/d) to therapy with oral corticosteroids reduced the number of relapses of patients with acute asthma who had been discharged from the emergency department. These data, together with the study by Rodrigo and Rodrigo,12 suggest that patients with an acute asthma exacerbation may benefit from therapy with both systemic and inhaled corticosteroids in the emergency department and after discharge.
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