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.
- 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
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