Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Short-term oral prednisone reduced relapse after acute asthma

ACP J Club. 1991 Jul-Aug;115:1. doi:10.7326/ACPJC-1991-115-1-001


Source Citation

Chapman KR, Verbeek PR, White JG, Rebuck AS. Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma. N Engl J Med. 1991 Mar 21;324:788-94. [PubMed ID: 1997850]


Abstract

Objective

To determine the effectiveness of a short course of oral prednisone in preventing relapse after emergency room treatment for asthma.

Design

Randomized, double-blind, controlled trial.

Setting

Emergency rooms at 2 large teaching hospitals in Toronto, Ontario, Canada.

Patients

Patients who were treated in the emergency room for acute asthma were referred to the study by emergency room physicians if the patient was likely to be sent home after treatment. 102 patients met inclusion criteria including age ≥ 16 years, a diagnosis of asthma according to American Thoracic Society criteria, and no steroids in the previous 4 weeks. 88 patients completed the trial.

Intervention

Study treatment consisted of an 8-day tapering course of oral prednisone, 40 mg the first 2 days, then 5 mg less each day, or placebo, along with an inhaled β2-agonist and theophylline.

Main outcome measure

Relapse, defined as worsening or nonresponse of asthma, resulting in the patient seeking medical attention.

Main results

Using an intention-to-treat analysis, during the first 10 days after emergency room treatment there were fewer relapses in the prednisone group (5 of 48 patients, 18%) than in the placebo group (13 of 45 patients 29%) (P < 0.05). {This absolute risk reduction of 11% means that 9 patients would need to be treated with prednisone (compared with placebo) to prevent 1 additional relapse, 95% CI 3 to 40; the relative risk reduction was 64%, CI 11% to 86%.}.* This difference remained significant to day 21, although there was no further significant difference in relapse rates between treatment groups between days 11 and 21. There was no effect of age, concomitant medication use, previous hospitalizations, or duration of exacerbation of asthma on the benefit of therapy. Benefit was limited to patients with an emergency room discharge FEV1 < 59% of the predicted value, in whom the relapse rates were 50% and 13% for the placebo and prednisone groups, respectively (P < 0.05). The 2 groups did not differ for symptom scores for "tightness or wheezing," "cough or congestion," "feeling tired or worn out," or "difficulty sleeping," but the mean daily symptom score for "shortness of breath" was better for the prednisone group (P < 0.01).

Conclusion

Ambulatory patients with asthma receiving regular maintenance therapy and a short course of oral prednisone after emergency room treatment for acute asthma had fewer relapses than patients on maintenance therapy and placebo.

Source of funding: PSI Foundation.

Address for article reprint: Dr. K.R. Chapman, Toronto Hospital Asthma Centre, 399 Bathurst Street, 4th Floor, Edith Cavell Wing, Toronto, Ontario M5T 2S8, Canada.


Updated Commentary

Since Chapman and colleagues' original paper in 1991 (1), our understanding of the role of corticosteroids, both systemic and inhaled, in acute asthma has evolved. The role of oral prednisone in preventing asthma relapse after discharge from the emergency room has been confirmed in a Cochrane Review (2). In addition, no need exists for tapering prednisone in patients currently receiving inhaled corticosteroids (3). In patients discharged from the emergency department, budesonide, 2.4 mg in 4 divided doses, has been shown to be as effective as prednisone 40 mg/d in preventing relapse (4). More recently Rowe and colleagues (5) randomized patients at discharge from the emergency room to either prednisone, 50 mg, or prdnisone and budesonide, 1600 mg. Patients in the combination group were less likely to relapse (12.8%, 95%CI 7% to 21%) than those in the prednisone-alone group (24.5%, CI 16% to 34%, P= 0.049). This is equivalent to a 48% relative risk reduction and gives a number needed to treat of 9.

The potential role of inhaled corticosteroids in patients with acute asthma was studied in a trial by Rodrigo and Rodrigo (6), which showed that inhaled flunisolide 1 mg every 10 minutes with salbutamol had an addictive effect compared with inhaled salbutamol alone. These data show that inhaled corticosteroids can be complimentary to the previously defined role of systemic corticosteroids and in appropriate doses are equivalent to oral prednisone. Although the issue of cost-effectiveness is important, in the absence of an effect of doubling the dose of inhaled corticosteroids (7) in an asthma exacerbation, tripling and possibly quadrupling the maintenance dose of inhaled corticosteroids may be required.

J. Mark FitzGerald, MB
University of British ColumbiaVancouver, British Columbia, Canada.


References

1. Chapman KR, Verbeek PR, White JG, Rebuck AS. Effect of a short course of prednisone in the prevention of early relapse after emergency room treatment of acute asthma. N Engl J Med. 1991;324:788-94.

2. Rowe BH, Spooner CH, Ducharme FM, et al. Early emergency department treatment of acute asthma with systemic corticoseroids. Cochrane Database Syst Rev. 2000(2):CD 002178 (latest version 02 Nov 2000).

3. O'Driscoll BR, Karla S, Wilson M, et al. Double blind trial of steroid tapering in acute asthma. Lancet. 1993;341:324-7.

4. Fitzgerald JM, Shragge DL, Haddon J, et al. A randomized controlled trial high dose inhaled budesonide versus oral prednisone in patients discharged from the emergency department following an acute asthma exacerbation. Can Respir J. 2000;7:61-7.

5. Rowe BH, Bota GW, Fabris L, et al. Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department: a randomized controlled trial. JAMA. 1999;281:2119-26.

6. Rodrigo G, Rodrigo C. Inhaled flunisolide for acute severe asthma. Am J Respir Crit Care Med. 1998;157:698-703.

7. FitzGerald JM, Becker A, Chung K, Lee J, and the Canadian Asthma Exacerbation Study Group. A randomized controlled, multi-center study to compare double dose versus maintenance dose of inhaled corticosteroids in during asthma exacerbations. Am J Respir Crit Care Med 2000;161:A187.