No Place Like Home For Oral Corticosteroids Ready for Asthma Exacerbation

Adult patients and parents of younger patients should be provided a supply of oral corticosteroid (OCS) to have on-hand at home with direction to use it for early intervention in asthma exacerbation, conclude pediatrics department faculty after assessing treatment interventions.

Miles Weinberger, MD, visiting clinical professor of pediatrics, University of California San Diego, and pediatric pulmonologist, Rady Children's Hospital, San Diego, California, and lead author of the perspective article, discussed the rationale for this strategy and why he and his colleagues have advocated for it.

"It is common practice to provide a means of inhaling albuterol to patients with asthma, but it is not common practice to provide an oral corticosteroid to have on hand for use when the albuterol is not effective," Weinberger told MD Magazine^®.

Weinberger explained that although a bronchodilator is effective for the bronchial smooth muscle constriction component of the airway obstruction of asthma, it does not relieve the inflammation that swells the mucous lining of the airways, and the secreted mucus that can block the airway.

"Oral corticosteroids are effective for that component, which is generally what drives patients to an emergency room (ER) and/or to get hospitalized," Weinberger said. "Oral or injected corticosteroids are provided at an ER or hospital, but earlier administration of an oral corticosteroid is likely to prevent the need for the ER visit or hospitalization."

In their perspective piece, Weinberger and colleagues examined the literature on corticosteroid treatment in exacerbations, with a particular focus on the variables in patient selection and corticosteroid dose and administration that likely influenced the study outcomes.

Acknowledging that conflicting results have been reported with the intervention, they found that studies conducted in children with a history of exacerbations severe enough to require acute care visits and hospitalizations were more likely to demonstrate a beneficial effect from early corticosteroid administration.

In 1 of the reviewed studies, for example, the administration of corticosteroids to 644 children with asthma exacerbation in emergency departments within 75 minutes of admission significantly improved outcomes in those receiving that treatment. Furthermore, the patients had a decreased hospital admission rate and length of active treatment compared to those receiving the treatment later in the admission.

"Even earlier administration would occur if [the] corticosteroid was given at home at the onset of a perceived exacerbation," Weinberger and colleagues argued.

Anticipating concerns about the adverse effects of corticosteroids, Weinberger and colleagues noted that there are relatively few issues related to short courses of corticosteroids, in contrast to their prolonged use. They also indicated that the prescribing physician should be able to manage against the possibility of prolonged or misuse of the at-home supply.

"[As] long as the physician providing the oral corticosteroid continues to follow the patient and requires review of usage prior to a refill, to be on hand for the next exacerbation, this is a safe strategy," Weinberger said. "Safer, in fact, than waiting for the patient to be seen in an ER or hospital or to overuse the albuterol."

The perspective article on keeping oral corticosteroids on-hand for asthma exacerbation was published in the July issue of the Annals of Allergy, Asthma and Immunology.