Steroids in Asthma: To Taper or Not to Taper?

Source: Cydulka RK, Emerman CL. A pilot study of steroid therapy after emergency department treatment of acute asthma: Is a taper needed? J Emerg Med 1998;16:15-19.

This is a small, carefully executed pilot study of patients treated in the emergency department for asthma exacerbation and judged suitable for discharge. No patients had concomitant respiratory disease and none had used steroids for two weeks prior to enrollment. Subjects were randomized to receive either an eight-day non-tapering course of prednisone 40 mg/d, or an eight-day tapering course of prednisone starting at 40 mg/d and reduced by 5 mg/d. All subjects had cortisol levels assayed and a cosyntropin stimulation test performed, both prior to receiving steroids and again 12 days after discharge. Fifteen subjects participated.

The tapering and non-tapering steroid groups demonstrated no differences in pulmonary function or rate of relapse during the 21-day study period. There was also no difference in plasma cortisol or response to cosyntropin stimulation test between the two groups. Cydulka and Emerman conclude that tapering of steroids does not result in clinical benefit and that a short course of steroids, with or without a taper, does not cause adrenal suppression.

Comment by David J. Karras, MD, FACEP

Because of its small size, this study lacks the power to state conclusive results regarding the need to taper steroids in asthmatic patients. The authors are not the first to demonstrate lack of benefit to steroid tapers; other studies have safely discontinued steroids abruptly after 10 days of therapy.1 The study is important nevertheless because, to my knowledge, it is the first to assess adrenal function after a short (8 day) course of steroids.

The absence of any evidence of adrenal suppression adds to the weight of evidence that short-tapering steroid regimens are unnecessary. These dosing regimens are complicated and confusing, which may diminish patient compliance. Dose-packs, designed to simplify tapering regimens, cost about $9 (generic wholesale price) while prednisone tablets cost literally a few pennies each. While steroid tapers continue to be commonly used in asthmatic patients, there does not appear to be any strong rationale for doing so for otherwise healthy patients receiving short courses of therapy.

Reference

    1. O'Driscoll BR, et al. Double-blind trial of steroid tapering in acute asthma. Lancet 1993;341:324-327.

Dr. Karras is Associate Professor of Medicine, Temple University School of Medicine, and Director of Emergency Medicine Research, Temple University Hospital, Philadelphia, PA.