Acute asthma: inhaled and oral steroids were better than oral steroids alone.

Clinical bottom line (level 1b)

  1. Patients with acute asthma who were treated and discharged from an emergency department, who received oral and inhaled corticosteroids compared with oral corticosteroids alone were less likely to relapse (NNT = 9 at 21 days) .
  2. The effect on subsequent hospital admission was unclear.
  3. Patients on inhaled and oral steroids were less likely to have side effects (sore throat, hoarse voice or nausea) (NNT = 7 at 21 days) .
Rowe et al: Journal of the American Medical Association 1999; 281 (22): 2119-2126
Expires June 2002

The study

Double-blinded concealed randomised trial with intention-to-treat
Setting: emergency department, community teaching hospital, Canada

188 patients (aged mean 27 years, 61% female) asthma (previous history of asthma, response to beta-2-agonists and worsening symptoms necessitating treatment in the emergency department; mean PEFR 50% predicted)

Excluded if
  • <16 or >60 years old
  • PEFR >80% predicted
  • on oral or inhaled corticosteroids during the previous week
  • presented for prescription renewals
  • complicated co morbid conditions (renal or cardiovascular diseases, HIV)
  • pregnant or breast-feeding
  • geographically inaccessible for follow-up


    • Note:
  • Patients were randomised in blocks of ten.


    • Control Group: (n = 94, 94 analysed): placebo
    Experimental Group: (n = 94, 94 analysed): inhaled budesonide 800 µ g twice daily
    All patients received nebulised beta-2-agonists every 20 minutes for the first hour, non-tapering course of oral prednisolone 50 mg/day for seven days, supplemental oxygen and, when indicated, nebulised ipratropium bromide. Patients were prescribed or continued on theophylline, long-acting beta-2-agonists, ipratropium bromide and antibiotics at the clinician's discretion. Patients were asked to stop nedocromil sodium or sodium chromglycate for the study duration, and avoid using other inhaled steroids.
    100% followed for 21 days
    Outcome notes:
    • relapse : unscheduled visit for worsening asthma symptoms
    • side effects : hoarse voice, sore throat, nausea

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    relapse 21 days 23
    (24.5%)    		 12
    (12.8%)    		 48%
    (1% to 72%)    		 11.7%
    (0.70% to 22.7%)    		 9
    (4 to 140)
    admission to hospital 21 days 2
    (2.13%)    		 1
    (1.06%)    		 50%
    (-442% to 95%)    		 1.06%
    (-2.52% to 4.64%)    		 94
    (NNT = 22 to infinity;
    NNH = 40 to infinity)
    side effects 21 days 49
    (52.1%)    		 35
    (37.2%)    		 29%
    (1% to 48%)    		 14.9%
    (0.84% to 29.0%)    		 7
    (3 to 120)

    Comments

    1. Study findings fit the overall approach of asthma care, with its emphasis on pro-active management to prevent episodes of shortness of breath.

    Citation

    1. 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. Journal of the American Medical Association 1999; 281 (22): 2119-2126
    Search Terms: hand search
    Contributor: Chris Ball and Clare Wotton, June 2000
    Reviewer: Chris van Weel

    Clinical Question.
    Patient asthma
    Intervention or Exposure inhaled steroid, budesonide
    Comparison placebo, oral steroid only
    Outcome relapse, admission