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Editorials: Point and Counterpoint |

Rebuttal From Dr Weinberger FREE TO VIEW

Miles Weinberger, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

Professor Emeritus of Pediatrics, University of Iowa, Iowa City, IA

CORRESPONDENCE TO: Miles Weinberger, MD, 450 Sandalwood Ct, Encinitas, CA 92024


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(3):494. doi:10.1016/j.chest.2016.06.025
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Published online

Dr Farber acknowledges the efficacy of oral corticosteroids but expresses concern regarding “significant toxicity even in short bursts.” However, examination of children requiring frequent short courses of oral glucocorticoids for acute asthma found no sustained adverse effects. A systematic review did find acute vomiting, transient behavioral changes, and sleep disturbances in 5.4%, 4.7%, and 4.3% of children, respectively, who were given a short course of an oral corticosteroid, predominantly prednisolone. However, vomiting is a formulation issue due to the extremely foul taste of some liquid formulations of prednisolone. Commercial formulations with better taste masking are available; an alternative is a crushed dexamethasone tablet given with sugar or a sweet soft food. The side effects of transient behavioral changes and sleep disturbances are annoying but neither dangerous nor universal. They need to be weighed against the behavioral effects and sleep disturbances associated with loss of asthma control. Moreover, clinical experience has found that those central nervous system effects of prednisolone are less common with methylprednisolone and dexamethasone. Although neither is available in a satisfactory pediatric liquid formulation, they can be given crushed with sweet soft food or sugar. The risk from varicella acquired during a short course of systemic corticosteroids is real and serious but avoidable with routine prior varicella immunization.

Because of his concern about the low frequency of transient adverse effects from (some) oral corticosteroids, Dr Farber suggests more complex alternatives such as a combination of an inhaled corticosteroid and bronchodilator used as desired by the patient. Although amelioration has been demonstrated from that strategy, the article referenced states that “no differences in symptom-free days and asthma control days were seen between the groups receiving the as-needed strategy and the fixed-dose combination.”(p1,738)

Although Dr Farber’s proposed strategies may provide amelioration that is sufficient for some patients, and spontaneous improvement may occur in others, a short course of an oral corticosteroid provides the simplest, most reliable, and most rapid response for treating acute loss of control, that is, an asthma exacerbation.

References

Farber H.J. . Point: Is escalation of the inhaled corticosteroid dose appropriate for acute loss of asthma control in an attempt to reduce need for oral corticosteroids in children? Yes. Chest. 2016;150:488-490 [PubMed]journal
 
Ducharme F.M. .Chabot G. .Polychronakos C. .Glorieux F. .Mazer B. . Safety profile of frequent short courses of oral glucocorticoids in acute pediatric asthma: impact on bone metabolism, bone density, and adrenal function. Pediatrics. 2003;111:376-383 [PubMed]journal. [CrossRef] [PubMed]
 
Aljebab F. .Choonara O. .Conroy S. . Systematic review of the toxicity of short-course oral corticosteroids in children. Arch Dis Child. 2016;101:365-370 [PubMed]journal. [CrossRef] [PubMed]
 
Hendeles L. . Selecting a systemic corticosteroid for acute asthma in young children. J Pediatr. 2003;142:S40-S44 [PubMed]journal. [CrossRef] [PubMed]
 
Qureshi F. .Zaritsky A. .Poirier M.P. . Comparative efficacy of oral dexamethasone verses oral prednisone in acute pediatric asthma. J Pediatr. 2001;139:20-26 [PubMed]journal. [CrossRef] [PubMed]
 
Bisgaard H. .Le Roux P. .BjÜmer D. .Dymek A. .Vermueulen J.H. .Hultquist C. . Budesonide/formoterol maintenance plus reliever therapy: a new strategy in pediatric asthma. Chest. 2006;130:1733-1743 [PubMed]journal. [CrossRef] [PubMed]
 
Harris J.B. .Weinberger M. .Nassif E. .Smith G. .Milavetz G. .Stillerman A. . Early intervention with short courses of prednisone to prevent progression of asthma in ambulatory patients incompletely responsive to bronchodilators. J Pediatr. 1987;110:627-644 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Farber H.J. . Point: Is escalation of the inhaled corticosteroid dose appropriate for acute loss of asthma control in an attempt to reduce need for oral corticosteroids in children? Yes. Chest. 2016;150:488-490 [PubMed]journal
 
Ducharme F.M. .Chabot G. .Polychronakos C. .Glorieux F. .Mazer B. . Safety profile of frequent short courses of oral glucocorticoids in acute pediatric asthma: impact on bone metabolism, bone density, and adrenal function. Pediatrics. 2003;111:376-383 [PubMed]journal. [CrossRef] [PubMed]
 
Aljebab F. .Choonara O. .Conroy S. . Systematic review of the toxicity of short-course oral corticosteroids in children. Arch Dis Child. 2016;101:365-370 [PubMed]journal. [CrossRef] [PubMed]
 
Hendeles L. . Selecting a systemic corticosteroid for acute asthma in young children. J Pediatr. 2003;142:S40-S44 [PubMed]journal. [CrossRef] [PubMed]
 
Qureshi F. .Zaritsky A. .Poirier M.P. . Comparative efficacy of oral dexamethasone verses oral prednisone in acute pediatric asthma. J Pediatr. 2001;139:20-26 [PubMed]journal. [CrossRef] [PubMed]
 
Bisgaard H. .Le Roux P. .BjÜmer D. .Dymek A. .Vermueulen J.H. .Hultquist C. . Budesonide/formoterol maintenance plus reliever therapy: a new strategy in pediatric asthma. Chest. 2006;130:1733-1743 [PubMed]journal. [CrossRef] [PubMed]
 
Harris J.B. .Weinberger M. .Nassif E. .Smith G. .Milavetz G. .Stillerman A. . Early intervention with short courses of prednisone to prevent progression of asthma in ambulatory patients incompletely responsive to bronchodilators. J Pediatr. 1987;110:627-644 [PubMed]journal. [CrossRef] [PubMed]
 
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