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Editorials: Point and Counterpoint |

Rebuttal From Dr Farber FREE TO VIEW

Harold J. Farber, MD, MSPH, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST the following: H. J. F. serves as Associate Medical Director for Texas Children’s Health Plan, a not-for-profit Medicaid and CHIP managed care organization owned by Texas Children’s Hospital.

Pulmonary Section, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX

CORRESPONDENCE TO: Harold J. Farber, MD, MSPH, FCCP, Texas Children’s Hospital, Pulmonary Medicine Service, 6701 Fannin, Ste 1040.00, Houston, TX 77030


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


Chest. 2016;150(3):493. doi:10.1016/j.chest.2016.06.027
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Dr Weinberger asks what is loss of control? Are symptoms that need reliever medication a “full blown exacerbation”? Is the “yellow zone” simply a “procrastinator's zone”? Should we just cut to the chase and give oral corticosteroid medication any time a child has symptoms of asthma?

Is early initiation of oral corticosteroids by parents a good strategy? A clinical trial of 204 Medicaid-insured children with asthma 2 to 14 years of age in Baltimore, Maryland randomized participants to either prednisone or placebo for an attack that had not improved after a dose of the child's regular acute asthma medicine. They found a larger number of attacks resulting in ED visits in the group receiving prednisone and no difference in hospitalizations. Although the study assessments did not detect differences in side effects between the groups, it is possible that unmeasured side effects such as agitation or difficulty sleeping drove the parents to seek urgent/emergent medical attention. A clinical trial in the United Kingdom randomized 217 children 1 to 5 years with episodic wheezing associated with coryza to placebo or prednisolone for 5 days at onset of wheezing associated with coryza. There were no statistically significant differences in day or night symptom scores. Unexpectedly, the hospitalization rate was greater in the group receiving prednisolone (12% vs 3%), although the difference fell shy of the criteria for statistical significance (P = .06). Although oral corticosteroid medication has definite benefits for patients with a moderate to severe asthma exacerbation, these clinical trials suggest that for most patients, early initiation by parents is not beneficial.

In the past 25 years, we have gone from oral corticosteroid underuse to its overuse. An analysis of claims data from Texas Children’s Health Plan, a large Medicaid managed care program, found that 49% of children < 5 years and 41% of children 5 to 12 years with a diagnosis of asthma had a claim for a dispensed oral corticosteroid in the prior 12 months. It is difficult to imagine how this level of oral corticosteroid use is justified.

Dr Weinberger cites a review by Hendeles and Sherman as evidence against as-needed escalation of inhaled corticosteroids. This review was published in February of 2003 and was not able to include the more recent studies showing significant benefit of this strategy.

The sample case presented by Dr Weinberger describes cough progressing to dyspnea and interfering with sleep. This is already a moderate to severe exacerbation. The early mild stage was missed. The exacerbation was well established, and the window for benefit from escalation of the dose of inhaled corticosteroid medication had passed. I would postulate that if the patient had escalated or initiated the inhaled corticosteroid at the very start of respiratory symptoms, that is, at the very onset of respiratory symptoms or in parallel with the need for albuterol, the patient would stand a reasonable chance of attenuating the severity of the flare and may have avoided the need for oral corticosteroid medication.

References

Weinberger M. . Counterpoint: 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? No. Chest. 2016;150:490-492 [PubMed]journal
 
Grant C.C. .Duggan A.K. .DeAngelis C. . Independent parental administration of prednisone in acute asthma: a double-blind, placebo-controlled, crossover study. Pediatrics. 1995;96:224-229 [PubMed]journal. [PubMed]
 
Oommen A. .Lambert P.C. .Grigg J. . Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial. Lancet. 2003;362:1433-1438 [PubMed]journal. [CrossRef] [PubMed]
 
Rowe B.H. .Spooner C. .Ducharme F.M. .Bretzlaff J.A. .Bota G.W. . Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001;1:CD002178- [PubMed]journal. [PubMed]
 
Kothari V, Silveira EA, Giardino AP, Farber HJ. Oral corticosteroid use among children with asthma in a large Medicaid managed care program.Am J Respir Crit Care Med. 2014;189(Meeting Abstracts):A1810.http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2014.189.1_MeetingAbstracts.A1810. Accessed May 7, 2016.
 
Hendeles L. .Sherman J. . Are inhaled corticosteroids effective for acute exacerbations of asthma in children? J Pediatr. 2003;142:S26-S32 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Weinberger M. . Counterpoint: 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? No. Chest. 2016;150:490-492 [PubMed]journal
 
Grant C.C. .Duggan A.K. .DeAngelis C. . Independent parental administration of prednisone in acute asthma: a double-blind, placebo-controlled, crossover study. Pediatrics. 1995;96:224-229 [PubMed]journal. [PubMed]
 
Oommen A. .Lambert P.C. .Grigg J. . Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial. Lancet. 2003;362:1433-1438 [PubMed]journal. [CrossRef] [PubMed]
 
Rowe B.H. .Spooner C. .Ducharme F.M. .Bretzlaff J.A. .Bota G.W. . Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001;1:CD002178- [PubMed]journal. [PubMed]
 
Kothari V, Silveira EA, Giardino AP, Farber HJ. Oral corticosteroid use among children with asthma in a large Medicaid managed care program.Am J Respir Crit Care Med. 2014;189(Meeting Abstracts):A1810.http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2014.189.1_MeetingAbstracts.A1810. Accessed May 7, 2016.
 
Hendeles L. .Sherman J. . Are inhaled corticosteroids effective for acute exacerbations of asthma in children? J Pediatr. 2003;142:S26-S32 [PubMed]journal. [CrossRef] [PubMed]
 
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