Written by Michael Frein
A single dose of dexamethasone was as effective as two in treatment of mild to moderate pediatric asthma exacerbations in the emergency department.
Why does this matter?
Asthma exacerbations are a common presentation to pediatric emergency departments, with a very standardized treatment approach including breathing treatments and steroids. Single dose dexamethasone is more cost effective and efficient for families, as it does not require picking up a prescription; and single dose administration in the ED ensures 100% compliance. There have been multiple past studies showing similar efficacy of dexamethasone to prednisone or prednisolone, but is one dose of dexamethasone enough?
Drifting away from double dose dex?
This was a single-center, prospective, unblinded randomized clinical trial in ED patients age 2-20 that have already been previously diagnosed with asthma presenting with mild to moderate asthma exacerbations based on the pediatric asthma score (PAS). After exclusions and loss to follow up, 116 patients were allocated to each group. Group 1 received a single dose of 0.6 mg/kg (maximum of 16 mg) of dexamethasone orally in the ED. Group 2 received the same dose in the ED and was then sent home with a prescription for a second dose to be taken in 24 hours. Exclusion criteria included those presenting with severe asthma exacerbations (PAS >11), use of steroids in the last 2 weeks, chronic lung disease, and patients that vomited 2 doses of steroids in the ED.
The primary outcome of the study was return visits to the ED, urgent care, or primary care physician for persistent asthma symptoms. Secondary outcomes included missed school days, days of symptoms, and adverse effects. Between Group 1 (single dose) and Group 2 (two doses), there was no significant difference in terms of return visits to ED/urgent care/primary care office. Group 1 had 12.1% return visits for asthma symptoms and Group 2 had 10.3% return rate (OR 0.892, 95%CI 0.377 to 2.110). Additionally, there were no significant differences in any of the secondary outcomes between the two groups.
Limitations included the unblinded nature of the study, with no placebo used for the second dose. In addition, prescription fill rate and primary care follow-up was obtained through telephone calls and self-report by family and was not validated with the pharmacies or primary care offices. Although a larger study would be beneficial, transition to single dose dexamethasone treatment versus two doses should be considered in mild to moderate pediatric asthma exacerbations.
Single-Dose Dexamethasone Is Not Inferior to 2 Doses in Mild to Moderate Pediatric Asthma Exacerbations in the Emergency Department. Pediatr Emerg Care. 2022 May 3. doi: 10.1097/PEC.0000000000002727. Online ahead of print.
Reviewed by Clay Smith