Inhaled steroids for acute asthma following emergency department discharge

Edmonds M, Brenner BE, Camargo CA, Rowe BH

Published Online:

July 8, 2009

Acute asthma is a common cause of visits to emergency departments. Some people will have a relapse of acute asthma within two weeks of being discharged after apparently successful treatment. Beta-agonists drugs are used to dilate the muscle in the airways and corticosteroids drugs are used to counter the swollen airways. Corticosteroids can be inhaled (ICS) or taken orally (CS). Inhaled corticosteroids may reduce adverse effects and get to the airways more directly than oral corticosteroids. This review of trials found that there was insufficient evidence that inhaling corticosteroids as well as taking the drugs orally is better than oral use alone, after emergency department treatment for an asthma attack. There is also insufficient evidence that taking inhaled corticosteroids alone is as good as taking them orally, although there is some evidence to support using inhaled corticosteroids alone for mild asthma attacks after emergency department discharge. More research is needed.

Abstract (click to read)

Background:

Patients with acute asthma treated in the emergency department are frequently treated with inhaled beta-agonists and oral corticosteroids (CS) after discharge. The use of inhaled CS (ICS) following discharge may also be beneficial in acute asthma.

Objectives:

To determine the effect of inhaled corticosteroids (ICS) on outcomes in the treatment of acute asthma following discharge from the emergency department (ED).

Search strategy:

Randomised controlled trials (RCTs) were identified from the Cochrane Airways Review Group register which consists of systematic searches of EMBASE, MEDLINE and CINAHL databases supplemented by hand searching of 20 respiratory journals. In addition, abstracts from conferences were searched; primary authors and pharmaceutical companies were contacted to identify eligible studies. Bibliographies from included studies, known reviews, and texts also were searched.

Selection criteria:

Only RCTs or quasi RCTs were eligible for inclusion. Studies were included if patients were treated for acute asthma in the ED or its equivalent, and following ED discharge were treated with ICS therapy either in addition to, or as a substitute for, oral corticosteroids (CS). Two reviewers independently assessed articles for potential relevance, final inclusion, and methodological quality.

Data collection and analysis:

Data were extracted independently by two reviewers if the authors were unable to verify the validity of information. Several authors and pharmaceutical companies provided unpublished data. The data were analysed using the Cochrane Review Manager.

Main results:

Ten trials were selected for inclusion. Three of these trials, involving a total of 909 patients, compared ICS plus CS Vs CS therapy alone. There was no demonstrated benefit of ICS therapy when used in addition to CS therapy in the trials. Relapses were reduced, but not significantly, with the addition of ICS therapy (OR: 0.68; 95% CI: 0.46 to 1.02). As well, no differences were demonstrated between the two groups for relapses requiring admission, quality of life, symptom scores, or adverse effects.

Seven trials, involving a total of 1204 patients, compared high-dose ICS therapy alone Vs CS therapy alone after ED discharge. There were no significant differences demonstrated between ICS therapy alone and CS therapy alone for relapse rates (OR: 1.00; 95% CI: 0.66 to 1.52) or in the secondary outcomes of beta-agonist use, symptoms, or adverse events. However, the sample size was not adequate to confidently exclude the possibility of either treatment being significantly inferior, and severe asthmatics were excluded from these trials.

Update searches conducted in February 2002 and February 2003 did not yield any new studies for inclusion in the review.

Authors' conclusions:

There is insufficient evidence that ICS therapy provides additional benefit when used in combination with standard CS therapy upon ED discharge for acute asthma. There is some evidence that high-dose ICS therapy alone may be as effective as CS therapy when used in mild asthmatics upon ED discharge; however, there is a significant possibility of a type II error in drawing this conclusion. Further research is needed to clarify whether ICS therapy should be employed in acute asthma treatment in the ED or following ED discharge.

This record should be cited as:

Edmonds M, Brenner BE, Camargo CA, Rowe BH. Inhaled steroids for acute asthma following emergency department discharge. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002316. DOI: 10.1002/14651858.CD002316

Assessed as up to date:

February 7, 2003

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Primary Review Group:

Airways Group

Asthma topics:

Treating with Medications > Asthma Attacks > Steroids, inhaled

Health topics:

Lungs & airways > Asthma (acute) > Corticosteroids

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Inhaled steroids for acute asthma following emergency department discharge

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