Asthma: exacerbation: adding inhaled steroids to oral steroids following emergency department discharge does not clearly reduce relapse

Clinical bottom line (level 1a-)

  1. Patients discharged from an emergency department following treatment for acute asthma who receive inhaled and oral steroids compared with oral steroids alone are not clearly less likely to relapse in the next 3 weeks.
  2. Patients discharged from an emergency department following treatment for acute asthma who receive inhaled steroids compared with oral steroids are not clearly less likely to relapse in the next 3 weeks.
Edmonds et al: Cochrane Library 2000; 3 : -
Expires October 2003

The study

Systematic review of all randomised or quasi-randomised controlled trials of
  • Patients: treated acute asthma in an emergency setting and then discharged
  • Intervention: inhaled steroids (+/- oral steroids) compared with oral steroids
  • Outcome: relapse

    Articles found in ?all languages using Cochrane Airways Review Group register (derived from Medline, Embase, CINAHL, CENTRAL and hand-searching of 20 respiratory journals, - (search terms: detailed in text ) and searching abstracts of conferences and bibliographies of included stuides, known reviews and texts. Primary authors and pharmaceutical companies were contacted to identify eligible studies.

    Selection criteria: by 2 independent reviewers
    Appraisal criteria: by 2 independent reviewers using Jadad criteria
    Articles excluded if:
    • children aged under 2


    10 studies found, 6 adult, 4 paediatric. 3 involving 909 patients comparing inhaled and systemic steroids with systemic steroids alone; 7 involving 1204 patients comparing inhaled steroids with systemic steroids
    Significant heterogeneity was noted for symptom improvement and beta-agonist use and quality of life..

    The evidence

    Outcome Time to outcome CER OR
    (95% CI)    		 NN T
    (95% CI)
    inhaled + systemic steroids v. systemic steroids: relapse 3 weeks 64/454
    (14.1%)    		 0.68
    (0.46 to 1.02)     		25
    (NNT = 14 to infinity;
    NNH = 410 to infinity)
    inhaled v. systemic steroids 3 weeks 46/214
    (21.5%)    		 1.26
    (0.80 to 1.98)     		-24
    (NNT = 28 to infinity;
    NNH = 7 to infinity)

    Comments

    1. No children took part in the studies comparing inhaled and systemic steroids with systemic steroids alone
    2. No differences in adverse effects or pulmonary function were noted between the two groups.
    3. There is insufficient evidence to indicate whether inhaled steroids are equivalent to oral steroids for preventing relapse in discharged patients.

    Citation

    1. Edmonds ML, Carnargo CA, Brenner BE, et al: inhaled steroids in acute asthma following emergency department discharge. Cochrane Library 2000; 3 : -
    Search Terms: asthma in Cochrane Library
    Contributor: Chris Ball, October 2001
    Reviewer:

    Clinical Question.
    Patient acute asthma discharged following treatment in an emergency department
    Intervention or Exposure inhaled steroids (+/- systemic steroids)
    Outcome relapse