Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Steroid tapering was not necessary after an initial course of prednisolone in patients hospitalized for acute asthma

ACP J Club. 1993 July-Aug;119:7. doi:10.7326/ACPJC-1993-119-1-007


Source Citation

O'Driscoll BR, Kalra S, Wilson M, et al. Double-blind trial of steroid tapering in acute asthma. Lancet. 1993 Feb 6;341:324-7.


Abstract

Objective

To determine if there is any advantage of a 1-week tapering course of oral prednisolone compared with an abruptly terminated course in patients hospitalized with acute asthma.

Design

Randomized, double-blind, placebo-controlled trial with 28-day follow-up.

Setting

2 university hospitals in the United Kingdom.

Patients

39 patients (age range 16 to 55 y) hospitalized with acute asthma, defined as peak expiratory flow rate (PEFR) < 65% of predicted, who were using an inhaled steroid (400 to 2000 µg/d) on discharge. Exclusion criteria were inability to maintain a PEFR diary for 28 days, major illnesses, chronic obstructive pulmonary disease, use of long-term oral steroids or maintenance nebulized treatment at home, intravenous hydrocortisone therapy for > 2 days, or mechanical ventilation. 35 patients (mean age 32 y) completed the trial.

Intervention

All patients received 40 mg of enteric-coated prednisolone daily for 10 days, followed by a tapering course with either 5-mg tablets of prednisolone (active taper, n = 18) or placebo tablets (placebo taper, n = 17). The dose was then reduced from 7 tablets on day 11 to no tablets by day 18. Patients could use bronchodilator therapy as prescribed with no alterations in use from day 10 to day 28.

Main outcome measures

PEFR on waking, 30 minutes after the first bronchodilator treatment, and at bedtime. Patients measured PEFR using a Mini-Wright peak flow meter (Clement Clark International, London, United Kingdom) and recorded results in a trial diary for 28 days (10 days beyond the end of the taper period). Patients also recorded asthma symptoms every day.

Main results

Both groups achieved peak flow rates near 400 L/min by day 10 and remained stable throughout the remaining 18 days of follow-up. The PEFR values remained almost identical during the entire post-treatment period (P = 0.8). On day 18, PEFR on waking was 399 L/min in the active taper group compared with 407 L/min in the placebo taper group (95% CI for the difference -67 to 51 L/min). On day 27 the PEFR was 386 L/min in the active treatment group compared with 412 L/min in the placebo group (CI -85 to 33). Symptom scores did not differ (P = 0.9).

Conclusion

A tapering course of steroids was not necessary after an initial course of 40 mg of prednisolone daily for 10 days in patients hospitalized for acute asthma.

Source of funding: In part, Pfizer UK Ltd.

For article reprint: Dr. B.R. O'Driscoll, Consultant in General and Thoracic Medicine, Hope Hospital, Salford M6 8HD, United Kingdom. FAX 44-61-787-4328.


Commentary

The strength of some guidelines on the management of asthma is limited by the lack of good evidence from clinical trials (1). The study by O'Driscoll and colleagues supports the conclusion that the common practice of tapering the dose of steroids does not improve the control of acute asthma. This study is in agreement with 2 other controlled trials of tapering (2, 3), thus providing strong evidence to guide clinical practice. Advantages are simpler treatment regimens and the reduced cumulative dose of steroids.

The treatment plan the investigators used raises some of the uncertainties in asthma management (1). First, it is difficult to define the level of severity of acute asthma at which systemic steroids should be started; a PEFR of < 50% of predicted or personal best is a frequent guide, but asthma severe enough to require oral steroids may be associated with a PEFR > 50% of best. Second, the outcome measures in this study fit the aims of treatment for acute asthma—to relieve symptoms and restore lung function (PEFR) to normal or personal best—but the dose and duration of steroid treatment needed to achieve this outcome are not established. The steroid regimen used, however, is similar to common practice and control—that is, patients achieved maximum PEFR and minimum symptoms in 10 days. Finally, recurrence of severe asthma after an acute attack has been treated is always a possibility. Lederle and colleagues (2) observed a 40% to 50% exacerbation rate and a 20% re-admission rate, which was much higher than in O'Driscoll and colleagues' study. This difference was at least partly caused by the longer follow-up of the Lederle study because most recurrences were 8 to 12 weeks after the acute attack, which emphasizes the need for continued surveillance. The problem of detection and treatment of recurrence was managed by written instructions based on measurement of PEFR and a plan for emergency treatment of more severe asthma. The frequency of recurrence may be reduced by regular use of inhaled steroids in an adequate dose (1).

Gerard Ryan, MD
Sir Charles Gairdner HospitalNedlands, Australia


References

1. National Heart, Lung, and Blood Institute. International consensus report on diagnosis and treatment of asthma. Eur Respir J. 1992;5:601-41.

2. Lederle FA, Pluhar RE, Joseph AM, et al. Tapering of corticosteroid therapy following exacerbation of asthma. A randomized, double-blind, placebo-controlled trial. Arch Intern Med. 1987;147:2201-3.

3. Hatton MQ, Vathenen AS, Allen MJ, Davies S, Cooke NJ. A comparison of 'abruptly stopping' with 'tailing off' oral corticosteroids in acute asthma. Respir Med. 1995;89:101-4.