Steroids for asthma exacerbations is commonly used by doctors. Asthma is characterized by many patients with recurrent exacerbations. Asthma exacerbations fill emergency rooms and are a major cause of hospitalizations. In the ER the treatment consists primarily of albuterol and systemic steroids. Albuterol is readily given at home, but oral steroids such as prednisone or medrol dose packs are not routinely prescribed for home use. Here we look at whether if it could be given to patients before the need for urgent medical care.
What is an Asthma Exacerbation?
Acute asthma is when the symptoms become more frequent or severe and do not improve with albuterol. This can lead to prolonged respiratory symptoms that interfere with sleep and activity and lead to urgent care or hospitalizations. Airways swell up and mucus secretions narrow the bronchioles.
Can oral steroids help asthma exacerbations?
Past studies have shown high dose systemic steroids in the emergency room decreased the frequency of hospital admissions as early as 3 hours after treatment. If steroids work quickly in the ER, the question that should be asked is it more effective if its administered at home?
Do high dose inhaled steroids work for exacerbations?
This is a strategy used by many doctors. At the onset of asthma exacerbations, many physicians recommend increasing the dose of inhaled steroids, sometimes giving 5X the amount of the maintenance dose. Multiple studies have shown that this does not work.
Do oral steroids work for asthma exacerbations?
Prednisone or prednisolone are commonly given for asthma flare ups. Studies have shown reductions in asthma symptoms, health resource use and school absenteeism. Another study showed 90% fewer hospitalizations in the treatment group compared to a group who received placebo. Overall, there seems to be significant beneficial effects from early steroid administration.
Which patients would benefit most from oral steroids?
Some studies have shown only a modest improvement with oral steroids as some patients spontaneously improve. Guidelines recommend a dose of 1-2 mg/kg/day for children, with an upper dosage of 60mg. Preschool children who have exacerbations with viral illnesses have shown an absence of benefit from oral steroids. Studies have shown the earlier the administration of steroids decreased hospital admission rates and length of treatment, supporting the use of giving it at home.
What are the risks of giving oral steroids?
Prolonged use of daily steroids is associated with growth suppression, change in body habitus and bone demineralization. However, short courses of oral steroids does not seem to show that risk.
Providing albuterol for patients with acute asthma is routinely done for all patients. But perhaps having oral steroids (prednisone) on hand for acute exacerbations is rational. Using it in a timely manner can decreased morbidity, urgent care and hospitalizations. Although routine of it is not recommended, if you have the need to use frequent oral steroids, speak to your asthma doctor about using or stepping on your controller medication.
Recent guidelines are suggesting for asthma exacerbations a Single Maintenance and Reliever Therapy (SMART) can be used. This will consist of of a long acting beta agonist (LABA) and an inhaled steroid. Examples of these are Advair, Symbicort or Dulera.
SMART is recommended by the Global Initiative for Asthma Guidelines for steps 3, 4, and 5. Low, medium, or high inhaled steroids is determined by the treatment step.
SMART therapy compared with standard therapy (albuterol as needed) has been found to reduce asthma exacerbation and prolonged time to first exacerbation in multiple trials.
Patients generally use their short acting beta 2 agonists when faced with an asthma exacerbation instead of also using an inhaled steroids. The SMART therapy seems to reduce exacerbation by providing additional anti-inflammatory treatment during the the time when airway inflammation is worsening, it has been found to be safe and effective.