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Replacement of Oral Corticosteroids With Inhaled Corticosteroids in the Treatment of Acute Asthma Following Emergency Department Discharge^*

A Meta-analysis

^* From the Division of Emergency Medicine, University of Alberta (Drs. Edmonds and Rowe), Edmonton, AB, Canada; the Department of Emergency Medicine (Dr. Camargo), Massachusetts General Hospital and Harvard Medical School, Boston, MA; and the Department of Emergency Medicine (Dr. Brenner), University of Arkansas, Little Rock, AR.

Correspondence to: Brian H. Rowe, MD, MSc, Division of Emergency Medicine, University of Alberta Faculty of Medicine and Dentistry, 1G1.63 Walter Mackenzie Centre, 8440-112th St, Edmonton, AB, Canada T6G 2B7;

Objectives: Oral corticosteroids (CS) are standard treatment for patients discharged from the emergency department (ED) after treatment for acute asthma. Several recent, relatively small trials have investigated the replacement of CS with inhaled corticosteroids (ICS), with varied results and conclusions. This systematic review examined the effect of using ICS in place of CS on outcomes in this setting.

Methods: Only randomized controlled trials were eligible for inclusion. Studies in which patients were treated for acute asthma in the ED or its equivalent, and on discharge compared ICS therapy to standard CS therapy, were eligible for inclusion. Trials were identified using the Cochrane Airways Review Group register, searching abstracts and bibliographies, and contacting primary authors and pharmaceutical companies. Data were extracted and methodologic quality assessed independently by two reviewers, and missing data were obtained from authors.

Results: Seven trials, involving a total of 1,204 patients, compared high-dose ICS therapy vs CS therapy after ED discharge. There were no significant differences demonstrated between the treatments for relapse rates (odds ratio, 1.00; 95% confidence interval, 0.66 to 1.52) or in the secondary outcomes of ß-agonist use, symptoms, or adverse events. However, the sample size was not adequate to prove equivalence between the treatments, and severe asthmatics were excluded from these trials.

Conclusions: There is some evidence that high-dose ICS therapy alone may be as effective as CS therapy when used in mild asthmatics on ED discharge; however, there is a significant possibility of a type II error in drawing this conclusion.

Key Words: asthma • corticosteroids • emergency department • inhaled corticosteroids • prevention • relapse

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