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Review
. 2012 Dec 12;12(12):CD002316.
doi: 10.1002/14651858.CD002316.pub2.

Inhaled steroids for acute asthma following emergency department discharge

Marcia L Edmonds  1 , Stephen J Milan, Barry E Brenner, Carlos A Camargo Jr, Brian H Rowe
Affiliations
Review

Inhaled steroids for acute asthma following emergency department discharge

Marcia L Edmonds et al. Cochrane Database Syst Rev. .

Abstract

Background: Patients with acute asthma treated in the emergency department (ED) are frequently treated with inhaled beta(2)-agonists and systemic corticosteroids after discharge. The use of inhaled corticosteroids (ICS) following discharge may also be beneficial in improving patient outcomes after acute asthma.

Objectives: To determine the effectiveness of ICS on outcomes in the treatment of acute asthma following discharge from the ED. To quantify the effectiveness of ICS therapy on acute asthma following ED discharge, when used in addition to, or as a substitute for, systemic corticosteroids.

Search methods: Controlled clinical trials (CCTs) were identified from the Cochrane Airways Review Group register, which consists of systematic searches of EMBASE, MEDLINE and CINAHL databases supplemented by handsearching of respiratory journals and conference proceedings. In addition, primary authors and pharmaceutical companies were contacted to identify eligible studies. Bibliographies from included studies, known reviews and texts also were searched. The searches have been conducted up to September 2012

Selection criteria: We included both randomised controlled trials (RCTs) and quasi-RCTs. Studies were included if patients were treated for acute asthma in the ED or its equivalent, and following ED discharge were treated with ICS therapy either in addition to, or as a substitute for, oral corticosteroids. Two review authors independently assessed articles for potential relevance, final inclusion and methodological quality.

Data collection and analysis: Data were extracted independently by two review authors, or confirmed by the study authors. Several authors and pharmaceutical companies provided unpublished data. The data were analysed using the Cochrane Review Manager software. Where appropriate, individual and pooled dichotomous outcomes were reported as odds ratios (OR) or relative risks (RR) with 95% confidence intervals (CIs). Where appropriate, individual and pooled continuous outcomes were reported as mean differences (MD) or standardized mean differences (SMD) with 95% CIs. The primary analysis employed a fixed effect model and heterogeneity is reported using I-squared (I(2)) statistics.

Main results: Twelve trials were eligible for inclusion. Three of these trials, involving a total of 909 patients, compared ICS plus systemic corticosteroids versus oral corticosteroid therapy alone. There was no demonstrated benefit of ICS therapy when used in addition to oral corticosteroid therapy in the trials. Relapses were reduced; however, this was not statistically significant with the addition of ICS therapy (OR 0.68; 95% CI 0.46 to 1.02; 3 studies; N = 909). In addition, no statistically significant differences were demonstrated between the two groups for relapses requiring admission, quality of life, symptom scores or adverse effects.Nine trials, involving a total of 1296 patients compared high-dose ICS therapy alone versus oral corticosteroid therapy alone after ED discharge. There were no significant differences demonstrated between ICS therapy alone versus oral corticosteroid therapy alone for relapse rates (OR 1.00; 95% CI 0.66 to 1.52; 4 studies; N = 684), admissions to hospital, or in the secondary outcomes of beta(2)-agonist use, symptoms or adverse events. However, the sample size was not adequate to exclude the possibility of either treatment being significantly inferior and people with severe asthma were excluded from these trials.

Authors' conclusions: There is insufficient evidence that ICS therapy provides additional benefit when used in combination with standard systemic corticosteroid therapy upon ED discharge for acute asthma. There is some evidence that high-dose ICS therapy alone may be as effective as oral corticosteroid therapy when used in mild asthmatics upon ED discharge; however, the confidence intervals were too wide to be confident of equal effectiveness. Further research is needed to clarify whether ICS therapy should be employed in acute asthma treatment following ED discharge. The review does not suggest any reason to stop usual treatment with ICS following ED discharge, even if a course of oral corticosteroids are prescribed.

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Conflict of interest statement

The authors who have been involved in this review have done so without any known conflicts of interest. Drs. Rowe, Brenner and Camargo were involved as lead investigators in the primary studies of oral corticosteroid plus ICS versus oral corticosteroid alone. Drs. Camargo, Rowe and Brenner have received unrestricted educational grants for research from Astra, Boehringer‐Ingelheim, Forest, Glaxo Wellcome, Merck and Sepracor. However, none of the authors is considered a paid consultant by any pharmaceutical company that produces ICS agents.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Forest plot of comparison: 1 Any ICS plus oral corticosteroid versus oral corticosteroid, outcome: 1.1 Asthma relapse at 7‐10 days.
4
4
Forest plot of comparison: 1 Any ICS plus oral corticosteroid versus oral corticosteroid, outcome: 1.5 Beta2‐agonist use at 20‐24 days.
5
5
Forest plot of comparison: 2 Any ICS versus oral corticosteroid, outcome: 2.1 Asthma relapse at 7‐10 days.
6
6
Forest plot of comparison: 2 Any ICS versus oral corticosteroid, outcome: 2.2 Asthma relapse at 16‐21 days.
1.1
1.1. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 1 Asthma relapse at 7‐10 days.
1.2
1.2. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 2 Asthma relapse at 20‐24 days.
1.3
1.3. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 3 Hospital admission.
1.4
1.4. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 4 Beta2‐agonist use at 7‐10 days.
1.5
1.5. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 5 Beta2‐agonist use at 20‐24 days.
1.6
1.6. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 6 PEF at 7‐10 days.
1.7
1.7. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 7 PEF at 20‐24 days.
1.8
1.8. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 8 PEF% at 7‐10 days.
1.9
1.9. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 9 PEF% at 20‐24 days.
1.10
1.10. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 10 Quality of life at 7‐10 days.
1.11
1.11. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 11 Quality of life at 20‐24 days.
1.12
1.12. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 12 Cough at 7‐10 days.
1.13
1.13. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 13 Cough at 20‐24 days.
1.14
1.14. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 14 Wheeze at 7‐10 days.
1.15
1.15. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 15 Wheeze at 20‐24 days.
1.16
1.16. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 16 Dyspnoea at 7‐10 days.
1.17
1.17. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 17 Dyspnoea at 20‐24 days.
1.18
1.18. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 18 Hoarseness at 7‐10 days.
1.19
1.19. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 19 Hoarseness at 20‐24 days.
1.20
1.20. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 20 Sore throat at 7‐10 days.
1.21
1.21. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 21 Sore throat at 20‐24 days.
1.22
1.22. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 22 Asthma relapse at 7‐10 days ‐ gender subgroups.
1.23
1.23. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 23 Asthma relapse at 20‐24 days ‐ gender subgroups.
1.24
1.24. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 24 Asthma relapse at 7‐10 days; patients lost to follow‐up excluded.
1.25
1.25. Analysis
Comparison 1 Any ICS plus oral corticosteroid versus oral corticosteroid, Outcome 25 Asthma relapse at 20‐24 days; patients lost to follow‐up excluded.
2.1
2.1. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 1 Asthma relapse at 7‐10 days.
2.2
2.2. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 2 Asthma relapse at 16‐21 days.
2.3
2.3. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 3 Hospital admission.
2.4
2.4. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 4 PEF at 7‐10 days.
2.5
2.5. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 5 PEF at 16‐21 days.
2.6
2.6. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 6 PEF% at 7‐10 days.
2.7
2.7. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 7 PEF% at 16‐21 days.
2.8
2.8. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 8 FEV1% pred at 6‐10 days (outcome not pre‐specified in original review).
2.9
2.9. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 9 FEV1% pred at 16‐21 days (outcome not pre‐specified in original review).
2.10
2.10. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 10 Beta2‐agonist use at 7‐10 days.
2.11
2.11. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 11 Beta2‐agonist use at 14‐21 days.
2.12
2.12. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 12 Quality of life at 7‐10 days.
2.13
2.13. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 13 Cough at 7‐10 days.
2.14
2.14. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 14 Wheeze at 7‐10 days.
2.15
2.15. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 15 Wheeze at 16‐21 days.
2.16
2.16. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 16 Hoarseness at 7‐10 days.
2.17
2.17. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 17 Hoarseness at 16‐21 days.
2.18
2.18. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 18 Sore throat at 7‐10 days.
2.19
2.19. Analysis
Comparison 2 Any ICS versus oral corticosteroid, Outcome 19 Sore throat at 16‐21 days.
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References to studies awaiting assessment

Acun 2003 {published data only}
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References to other published versions of this review

Edmonds 2000
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