Notes From the Community – What’s the Best Oral Steroid for Asthma

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Patrick B. -

One of the most needed talks of the past decade. Thanks guys

JOHN C. -

Hi guys. Thanks for this. Do you have a reference for the length of action for the steroids (i.e. the 54 hrs you mentioned for dexamethasone)?

Stephen G. -

I have to take issue with the comment by Andy (pardon if I don't remember verbatim "if [the pcp] knew what they were doing, they would have referred [to a pulmonologist]". Every kid with asthma does NOT need a referral to a pediatric pulmonologist. This is a primary care disease. We simply will be wasting the time of the specialists and of the parents if we were to refer all these kids to pulm. I'm boarded in EM and family medicine, and this one falls squarely in the hands of a capable pcp.

Rob O -

Hi John, Here are some references on steroid length of action from Andy Sloas...

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-4362.1990.tb04767.x/abstract

http://link.springer.com/article/10.2165/00003495-197816030-00006

http://onlinelibrary.wiley.com/doi/10.1002/mpo.2950190411/abstract

http://www.medicines.org.uk/emcmobile/medicine/8369/spc#PHARMACODYNAMIC_PROPS

http://www.patient.co.uk/doctor/corticosteroids-and-corticosteroid-replacement-therapy

John P. -

So what's the final word on whether or not you should consistently give/prescribe a second dose of dexamethasone and when should it be administered?

It seems like the logical thing to do would be to give one 0.6 mg/kg Dex dose in the ED followed by a repeat 0.6 mg/kg Dex dose 2 days later (approximately 56 hours later - after the first dose has worn off).

Andrew S. -

Stephen G -
While there are many PCP's out there who I'm quite certain know what they're doing with asthma, from what I have seen in the ER they're not taking the time to explain it to their patients. I stand by this statement. I see 100's of asthmatic kids come through the door without so much as an action plan and if they have an action plan it's to "start their inhaled steroid" and not to increase their beta agonist. If you asked me to bet whether or not the next 5 asthmatics I see tomorrow will have an action plan or look at me like a calf who's seeing a new gate for the first time when I ask them if they know what an action plan is, I'm quite sure it will be the latter and I'd bet the farm on it. If a child needs an inhaled steroid because they're having symptoms twice a week, night symptoms twice a month or going through two refills of a beta agonist a year then the PCP should have an action plan or have them seen by a pulmonologist. I believe that those patients are of the highest risk and probably are better off being seen by a pulmonolgist at least once, but if the PCP is completely comfortable than great keep up the good work. However, most that I see in the ER are still using nebs instead of MDIs, are as likely to have an adequate action plan as they are to need those inhaled steroids.

Andrew S. -

John P-
One dose may be as good as two on the Dex, but no one knows so I can't tell you for sure. I think if you ask the patient to wait for a day then they're likely to forget to take it so you may relapse on day 3 or 4, but again, just speculation. I use 0.6/kg in the ER and if the hospital allows me, I just give them the 2nd dose in the ER if I can. If working in a place where you can't give the second dose then write the Rx for the next day. The two back-back days was the same as Pred for 5d, but less relapse, less expensive, more compliance.

Kevin G. -

sticking up for PCPs, and using the evidence you provide, Dr Sloas, with last post to reply to your own re calves at gates:if the patient can't remember to take a second dose a day later, what's the odds they remember correctly when you ask that they DO have an action plan given to them by their ever so patient professional and caring PCP?

The problem may be in front of you, not with your colleague..

Daniel G., M.D. -

How's this for cheap and low tech? Take the decadron tablet and crush it with a spoon and sprinkle over apple sauce or chocolate pudding. Easy peasy and not unpalatable. The dose range is wide enough 0.15-0.6 (or 0.3-0.6) mg/Kg that if you lose a little, no big deal. My kids do fine with this.

Rob O -

Daniel, I like it! Nothing like the old mortar and pestle to get the job done.

Andrew S. -

Daniel G-

Great trick; I've done it myself. The only caution I give is that if the kid is really working to breath and you give the po they may vomit. Not a huge deal. Just redose it again when you put in the IV.

KB -

So I just want to make sure...you can use the IV dose and give that po? Literally draw up Iv formulation and give oral? this doesn't seem right.

Also if the average adult is 70kg, dosing at .15mg/kg will be a little over 10mg. If using the 10mg as your upper limit (as commented on the podcast) then most adults will be potential receiving the lower end or maybe not even therapeutic dose of dexmethasone. What are people practically using as an oral range for asthma in adults?

Andrew S. -

KB-

Yes, you absolutely have it right. You may give the IV prep PO. No ifs, ands, or buts... It tastes horrible so you want to have your pharmacist compound it. Here are the studies:

Chou JW, Decarie D, Dumont RJ, Ensom MH. Stability of dexamethasone in extemporaneously prepared oral suspensions. J Can Pharm Hosp. 2001;54:97-103.

Corneli HM, Zorc JJ, Mahajan P, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med. 2007;357:331-339.

Hames H, Seabrook JA, Matsui D, Rieder MJ, Joubert GI. A palatability study of a flavored dexamethasone preparation versus prednisolone liquid in children with asthma exacerbation in a pediatric emergency department. Can J Clin Pharmacol. 2008;15:e95-e98.

Yes you can give more Dex. If you want, give up to 16mg per the lit. The cerebral edema dose is 10mg, one study out there using 16mg, up to you which to choose at this point:

Kravitz J, Dominici P, Ufberg J, Fisher J, Giraldo P. Two days of
dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a
randomized controlled trial. Ann Emerg Med. 2011 Aug;58(2):200-4. doi:
10.1016/j.annemergmed.2011.01.004. Epub 2011 Feb 18. PubMed PMID: 21334098.

Jennifer C., MD -

Hey guys,

I'm late with this question as I just listened to Feb, but as a toxicologist (NERD) I had a pharmacokinetic question...I can't find anything saying that the IM decahedron lasts any longer than the po, just that it has a delayed onset of action (8-24 hrs), which might be problematic if the patient is sick enough to be in the ED. I'd like something that starts to work in a couple hours, as the po does, rather than 8-12. As far as duration, you mentioned 54 hours for the po, all I could fine for the IM was " less than 4 days" unless the long acting acetate formulation is used (and I think what we have the the ED is the shorter acting phosphate). So I suppose that could be up to 96 hours, but I am wondering if you guys found data that it actually lasts longer than the po, rather than just having a delayed peak of action? Thanks! Keep up the great work!

Andrew S. -

Jennifer C MD,

I agree with you IM does have a delayed onset compared to po and the only time I think it could be justified is if your patient is vomiting and you can't get an IV. In that case, I would probably pull out the US and get the IV so I could give fluids, ondansetron, dexamethasone, and have access in case I had to attempt intubation. I have no data that IM would work any longer; my understanding is that it takes longer to work but hangs around for the same amount of time.

Cheers-
Andy

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