Asthma: acute exacerbation: steroids did not need to be tapered off.

Clinical bottom line (level 1b)

  1. Patients with acute severe asthma who were discharged home on a course of steroids which were terminated abruptly, rather than tapered, did not have a significantly worse PEFR on stopping. nor were they clearly more likely to have an acute exacerbation.
  2. They were also not clearly more likely to have an asthma exacerbation.
O'Driscoll et al: Lancet 1993; 341: 324-327
Lederle et al: Archives of Internal Medicine 1987; 147: 201-203
Expires November 2002

The study

Double-blinded concealed randomised trial without intention-to-treat
Setting: two university hospitals, UK

39 patients (aged range 18 to 55 years; mean 32, ?% male) admitted to hospital with acute asthma (PEFR < 65% predicted)

Excluded if
  • <16 or >55 years
  • unable to maintain a PEFR diary for 28 days
  • major medical illness (especially pneumonia, heart failure, lung cancer or bronchiectasis)
  • COPD
  • on long-term steroids or maintenance nebulisers at home
  • unable to co-operate in trial
  • on iv hydrocortisone for > two days
  • required mechanical ventilation
  • included within two months


    • Control Group: (n = , 18 analysed): 10 days of 40 mg prednisolone po once daily, followed by 7 days of a tapering dose, starting at 35 mg on day 11, and decreasing by 5 mg daily until none on day 18
    Experimental Group: (n = , 17 analysed): 10 days of 40 mg prednisolone po once daily, followed by 7 days of placebo
    All patients were given a steroid inhaler on discharge (400 to 2000 mcg daily).
    90% followed for 28 days

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNH
    (95% CI)
    severe asthma exacerbation 28 days 1
    (5.56%)    		 1
    (5.88%)    		 -6%
    (-1460% to 93%)    		 -0.33%
    (-15.7% to 15.1%)    		 300
    (NNT = 7 to infinity;
    NNH = 6 to infinity)

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    day 18: PEFR on waking (best of three) (l/min) 399
    ()     		407
    ()     		8
    (-67 to 53)
    day 27: PEFR on waking (best of three) (l/min) 386
    ()     		412
    ()     		26
    (-85 to 33)

  • No significant difference was noted for PEFR or symptoms at any time between the two groups.

    • Comments

    1. The optimal dose and duration of steroid treatment for asthma exacerbation has not been addressed in this study.
    2. Follow up was relatively short at 28 days, and other studies (Lederle et al) have shown that most recurrences/relapses are between 8 to 12 weeks after an acute attack.
    3. Side-effects may indeed be less using abrupt cessation, as the total dose is lower.

    Citation

    1. O'Driscoll BR, Kalra S, Wilson M, et al: Double-blind trial of steroid tapering in acute asthma. Lancet 1993; 341: 324-327
    2. Lederle FA, et al: Tapering of Corticosteroid Therapy Following Exacerbation of Asthma. Archives of Internal Medicine 1987; 147: 201-203
    Search Terms: acute asthma in Cochrane
    Contributor: Benny Wong and Chris Ball, November 2000
    Reviewer: Mitsuhiro Kamei

    Clinical Question.
    Patient acute severe asthma
    Intervention or Exposure steroids tapered off
    Comparison steroids stopped abruptly
    Outcome PEFR, exacerbation