Asthma: low-dose steroids are probably as good as higher doses in acute attacks

Clinical bottom line (level 1a-)

  1. Patients with acute asthma attacks who take low dose steroids compared with higher doses have a similar improvement in FEV1 and PEFR at 48 hours.
  2. There is no clear effect on length of hospital stay.
Manser et al: Cochrane Library 1999; 3 : -
Expires November 2002

The study

Systematic review of all randomised controlled trials of
  • Patients: acute severe asthma, aged 16 to 65
  • Intervention: different doses of corticosteroids (any route): methylprednisolone, hydrocortisone, dexamethasone, prednisone, prednisolone, betamethasone or triamcinalone
  • Outcome: improvement in respiratory function

    Articles found in all languages using CINAHL, EMBASE, MEDLINE and CENTRAL, 1966 to 1998 (search terms: strategy detailed in text ) and handsearching of 20 respiratory journals, bibliographies of included studies, known reviews and texts. Primary authors and content experts were also contacted.

    Selection criteria: see above
    Appraisal criteria: by 2 independent reviewers, obtaining extra information from original authors where possible
    Articles excluded if:
    • follow-up less than 24 hours
    • not treated in emergency department or outpatient clinic
    • required mechanical ventilation


    9 studies found involving 344 adults (96 with low dose, 85 with medium dose and 163 with high dose corticosteroids). 6 used for meta-analysis.
    • Low dose: less than or equal to 80 mg methylprednisolone, 400 mg hydrocortisone, 100 mg prednisolone daily
    • Medium dose: 80 to 360 mg methylprednisolone, 400 to 1800 mg hydrocortisone, 100 to 450 mg prednisolone daily
    • high dose: more than 360 mg methylprednisolone, 1800 mg hydrocortisone, 450 mg prednisolone daily
    The studies were not found to be significantly heterogeneous.

    The evidence

    • FEV1 at 48 hours: low v. medium dose: weighted mean difference -3.3% (95% CI: -12.4% to 5.8%)
    • FEV1 at 48 hours: medium v. high dose: weighted mean difference: -1.9% (95% CI: -8.1% to 4.3%)
    • FEV1 at 48 hours: low v. high dose: weighted mean difference 0.5% (95% CI: -7.8% to 8.8%)
    • PEFR at 48 hours: medium v. high dose: weighted mean difference -2.9 (95% CI: -16.2 to 10.3)
    • length of stay: low or medium v. high dose: weighted mean difference 8 hours (95% CI: -4 to 21)

    Comments

    1. Adverse effects were reported inconsistently - there was insufficint data to relate these to dose.
    2. No deaths were reported.
    3. All the studies were small and had short follow-up. Few reported clinically significant outcomes. Consequently the potential benefits or risks of using high dose steroids are unclear.

    Citation

    1. Manser R, Reid D, Abramson M: corticosteroids in the management of hospitalised patients with acute severe asthma (Cochrane Review): Oxford, Update Software. Cochrane Library 1999; 3 : -
    Contributor: Chris Ball, October 1999
    Reviewer:

    Clinical Question.
    Patient
    Intervention or Exposure
    Outcome