Oral prednisone works best for asthma patients

Study shows alternative cuts hospital stays

Young asthma patients hospitalized with acute asthma attacks improve as well — or even faster — with oral corticosteroids as with intravenously administered methyprednisolone, according to a first-of-its-kind study from St. Christopher’s Hospital for Children in Philadelphia.

Children experiencing acute asthma exacerbations who received oral prednisone left the hospital eight hours earlier (70 hours vs. 78 hours) than those who received intravenous methyprednisolone. Those who required supplemental oxygenation used it for 22 hours less (30 hours vs. 52 hours) than those receiving what has long been viewed as the standard treatment.

Furthermore, children in the prednisone group were successfully weaned to ß2-agonists after 59 hours, compared to 68 hours in the methyprednisolone group.

What’s more, hospital treatment with oral corticosteroids costs one-tenth the price of the IV-administered medication and has the obvious benefit of being less-invasive and relatively simple to administer to frightened children.

That should make the use of oral corticosteroids the standard for care for inpatient treatment of acute asthma attacks, says Jack Becker, MD, lead author of the study, published in the April issue of the Journal of Allergy and Clinical Immunology, and chief of the section of allergy and professor of pediatrics at St. Christopher’s.

"Now there is no reason to use an IV in the average asthma patients," Becker says.

Bob Miles, MD, a Lynchburg, VA allergist and president of the American College of Allergy Asthma and Immunology is enthusiastic about Becker’s findings, but he is a little more cautious.

A new perspective

"It’s a landmark study because it has changed the idea that prednisone was too slow-acting to be a first choice in an acute situation," Miles says. "It’s a good study and should be considered applicable in practice, although we need more studies on this matter."

Miles says he is particularly enthusiastic about the possibility intravenous methyprednisolone will no longer be necessary for sick kids. "It will make it much nicer with no IVs."

Becker said he was surprised by the results of the randomized double-blind, double-placebo study conducted in 66 patients ages 2 to 18 admitted through the St. Christopher’s emergency department in late 1995 and early 1996 because, like Miles, he did not expect prednisone to be as effective as methyprednisolone.

"I thought this was a no-brainer. I went into this study thinking I would prove that intravenous methyprednisolone was better," Becker says. "I was a fan of that approach, but it didn’t turn out that way."

In fact, Becker estimates the reduction in hospital time from going the IV route would have been even greater, as much as half a day, if the group of subjects had been larger.

Even though this is the first inpatient study comparing the two forms of therapy, since 1997, the National Institutes of Health has recommended oral prednisone for hospitalized patients, apparently based on similar studies showing the two medications were at least equivalent but were not tested by randomized controlled trials.

"I am guessing they just extrapolated those studies," says Becker.

Becker’s study

Researchers compared prednisone, administered orally with a 2 mg/kg/dose b.i.d., up to a 120 mg/dose with intravenous methyprednisolone 1 mg/kg/dose q.i.d., up to a 60 mg/dose.

Children who had received oral corticosteroids in the previous five days or who had pneumonia or chronic lung disease were excluded.

All test subjects received either the prednisone or a sucrose pill and an intravenous solution either containing saline solution or methyprednisolone.

Supplemental oxygen was given to patients with a pulse oximetry of less than 95% and was discontinued when the patient’s pulse oximetry readings were 95% or above when the patient was breathing room air.

Nebulized ipratropium was given to patients who had received albuterol treatments in the 12 hours before they arrived in the emergency department and still were in significant distress.

The oral prednisone was mixed with either chocolate syrup or applesauce, if necessary, to make it more palatable to the young patients. Those who vomited the oral medication twice, complained of nausea or abdominal pain, or objected to the taste of the prednisone were removed from the study.

Becker says the cost savings in oral medication is significant. Based on cost data he obtained from four community hospitals and three university-based healthcare networks, costs for a 120 mg dose of prednisone ranged from $2 to $22, while the charges for 60 mg, considered an equipotent dose of methyprednisolone costs between $14 and $252.

Becker noted the limitations of his study. It included dosages of prednisone that are double the standard dosage. He says this allowed for nearly equipotent oral and intravenous dosages of corticosteroids. "Four milligrams of methyprednisolone has anti-inflammatory activity equal to 5 mg of prednisone," Becker wrote.

"Patients tolerated the higher dose of oral corticosteroid without significant side effects." He agrees that further studies will be required to determine optimal doses and frequency of administration of oral prednisone in the hospital setting.

[Jack Becker can be reached at (215) 427-8800.]