Dr. Julian Marsden (biography and disclosures)
What I did before
When faced with most asthma exacerbations my practice was often to treat with oral steroids for 7 days along with a salbutamol inhaler and leave the discussion regarding the prescription of a steroid inhaler to their family physician that they were to follow-up with. I never thought that the addition of an inhaled corticosteroid would add anything if they were taking it orally.
What changed my practice
I had a case of a young lady who I treated with salbutamol and prednisone and had follow-up at the end of her course of prednisone. She made an appointment for the day after the prednisone was completed. She presented to her family doctor in such respiratory distress that she had to be referred back (to me) and spent several hours in the Emergency Department and ultimately being admitted. Although in the end, she did well, this led me to reconsider how I treated asthma exacerbations and based on an article by Dr Brian Rowe, I have now made it routine practice to prescribe both oral and inhaled steroids to my asthma patients on discharge.
In 1999, Rowe, from Edmonton, published a definitive study on the role of inhaled steroids in the acute asthma exacerbations. It was a placebo controlled double-blind randomized trial involving 1006 consecutive patients age 16 – 60 years and after excluding those already on steroids, 188 were enrolled in the study. All patients received oral prednisone 50 mg/day for 7 days and received either inhaled budesonide 1600 μg/d or placebo for 21 days. After 21 days, 12 (12.8%)of 94 patients in the budesonide group experienced a relapsecompared with 23 (24.5%) of 94 in the placebo group, a 48% relapsereduction (P=.049).
What I do now
Given their effectiveness, safety, and ability to prevent relapses inhaled corticosteroids are now part of my discharge prescription for asthma exacerbations. I further justify it because some patients may not be able to follow up with a family physician and because this approach reinforces the value of inhaled steroids to the patient.
Additional reading:
- BC Guideline on Asthma: http://www.bcguidelines.ca/guideline_asthma.html#recommendation3
- FitzGerald JM. Asthma guidelines: Global to local. Ann Thorac Med [serial online] 2009 [cited 2012 Apr 30];4:161-2. Available from: http://www.thoracicmedicine.org/text.asp?2009/4/4/161/56006
Reference:
Rowe BH, Bota GW, Fabris L, et al. Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department: a randomized controlled trial. JAMA 1999; 281:2119–2126
http://jama.ama-assn.org/content/281/22/2119.full.pdf+html or with CPSBC
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I am an asthmatic myself and have discovered this phenomenon from self treatment. It has become standard therapy for my asthmatic patients.
I would be far more likely to treat with an inhaler before an oral steroid and would certainly never give oral without inhaled. It would seem to be a natural step up treatment to include both.
seems like a good idea, I always stopped the inhaled steroids in exacerbation when I added oral steroids, to save money for the patient, caused me to rethink, good article from Rowe.
Julian,
Do you leave patients on steroid inhalers indefinitely? Or is this just a 7-day course or until they see their regular physician?
Many asthmatic patients presenting to ER have already used the inhaled steroid (or a long acting beta-agonist + steroid). Do you recommend to try steroid inhalation, or PO steroid under such circumstance?
This is a good reminder. And even if they have a steroid, making sure they use it, and they properly use brings an interesting discussion.
In pediatrics it is difficult for young patients to comply but I have tried this above regime and it works.
V interesting
Interesting article as it is always nice to hear of evidence that supports what we’ve noticed in clinical practice.
Excellent reminder for me!
I do this for many years with great results, even extended the time of relapsed between each episode, and improve the condition of the patient
I have usually not given inhaled steroids when I prescribe systemic prednisone, as often my patients are already on inhaled steroids. But, I will try to be more aware and definitely try this approach.
I would check the technique of using inhaler first, as it may be the cause for failure of inhaler therapy. Oral steroids are certainly the step 3 of asthma management ( after bronchodilator alone, bronchodilator and inhaled steroid- always ensuring the technique)
SIGN and NICE have recommended step wise treatment of asthma- oral steroids are step3.
JAMA which has been quoted as reference chose patients who were not using initiated into using inhalers, and less than 10% used ICS-step2. Using short course steroids is not exactly step3, but patients are clearly ‘educated’ into step 3, than taking the opportunity of usefulness and technique of inhaler. Even though this is supposed to have happened in the JAMA Cohort, I guess, with a fair bit of cynicism that, this will the practice in the ‘crash, bang, wallop’ ED Patients.
Dispensing steroids will eventually be norm, just like the abused ativans and T3.-where it would have been an opportunity for education.
It should rather be, check technique, use ICS, and if fails, the, and only then, oral steroids.
And, this is with not to mention, the hassle in primary care it will create with coming for the ‘magic pill’
And, not to mention long term side effects of steroid abuse( yes, yes, I know, we use Ativan and T3 for short term panic attacks and the occasional back pain)