Dexamethasone for Pediatric Critical Asthma: A Multicenter Descriptive Study

Abstract

Background Systemic corticosteroids are vital to critical asthma management. While intravenous methylprednisolone is routinely used in the pediatric intensive care unit (PICU) setting, recent data supports dexamethasone as an alternative. Using the Pediatric Health Information System (PHIS) registry, we assessed trends and variation in corticosteroid prescribing among children hospitalized for critical asthma. Methods We performed a multicenter retrospective cohort study using PHIS data among children 3-17 years of age admitted for critical asthma from 2011 through 2019. Primary outcomes were corticosteroid prescribing rates by year and participating sites. Exploratory outcomes were corticosteroid-related adverse effects, rates of adjunctive pharmaceutical and respiratory interventions, mortality and length of stay. Results Of the 49 children's hospitals assessed, 26 907 encounters were included for study. Mean dexamethasone exposure rates were 18.1 ± 2.4% where 2.4 ± 1.2% represented dexamethasone-alone prescribing. Dexamethasone alone prescribing exhibited a linear trend (annual increase of 0.5 ± 0.1% annually R2 = 0.845) without correlation to cumulative site critical asthma admission rates. Compared to encounters prescribed solely methylprednisolone or a combination of dexamethasone and methylprednisolone, subjects provided dexamethasone alone had reduced asthma severity indices, length of stay, and exposure rates to adjunctive asthma interventions. Adverse events were rare and the dexamethasone-alone group less frequently experienced gastritis and hyperglycemia. Conclusions In this multicenter retrospective study from 49 children's hospitals, dexamethasone prescribing rates appear increasing for pediatric critical asthma. Observed variability in corticosteroid prescribing implies a continued need for controlled prospective comparative analyses to define ideal corticosteroid regimens for pediatric critical asthma.

Dexamethasone versus methylprednisolone for critical asthma: A single center, open‐label, parallel‐group clinical trial

“…Although prior survey data of United States pediatric intensivist respondents suggested a preference for IV methylprednisolone in cases of critical asthma, 14 wide variation in practice has been reported including a multicenter, registry‐based cohort study by Sellers et al who queried an administrative data set, the Pediatric Health Information System registry 15 . In their report including ~27,000 pediatric critical asthma encounters from 49 children's hospitals, dexamethasone‐only prescribing rates in the PICU exhibited a linear increase of 0.5% per year from 0.6% in 2011 to 4.5% in 2019.…”

“…Health Information System registry. 15 In their report including ~27,000 pediatric critical asthma encounters from 49 children's hospitals, dexamethasone-only prescribing rates in the PICU exhibited a linear increase of 0.5% per year from 0.6% in 2011 to 4.5% advantage for dexamethasone over methylprednisolone, prednisone, and prednisolone. Observational cohort data suggest two daily doses of dexamethasone may be equivalent to a 5-day course of prednisone or methylprednisolone.…”

“…[12][13][14] Yet, an increasing trend toward dexamethasone prescribing for severe exacerbations has been observed among PICU encounters. 15 Dexamethasone is a promising agent given its long elimination half-life (36−72 h) and potent glucocorticoid activity. 16 In the emergency department and general pediatric wards, observational data and systematic reviews suggest dexamethasone as an alternative to methylprednisolone as a result of observed reductions of inpatient length of stay (LOS), hospital relapse rates, gastrointestinal side effects, and direct costs.…”

“…In general, mild asthma exacerbations are managed with enteral prednisolone or prednisone and severe exacerbations with IV methylprednisolone for those unable to tolerate enteral formulations due to respiratory failure or altered mentation 12–14 . Yet, an increasing trend toward dexamethasone prescribing for severe exacerbations has been observed among PICU encounters 15 . Dexamethasone is a promising agent given its long elimination half‐life (36−72 h) and potent glucocorticoid activity 16 .…”

Wide Institutional Variability in the Treatment of Pediatric Critical Asthma: A Multicenter Retrospective Study

“…It is an observational study using a large, administrative database. Although the possibility for data entry and processing errors exists, data that are stored in the PHIS database undergo several quality checks before assimilation into the database and it has supported several studies of pediatric asthma (6, 35, 36). This study is observational in nature and subject to several potential biases, and any observed relationships are only associations, not causal.…”