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IV steroids in acute severe asthma

The current British Thoracic Society guidelines [1] on the management of acute asthma recommend the use of oral prednisolone or "intravenous hydrocortisone if severely ill or vomiting". It is common practice to administer 100-200 mg of intravenous hydrocortisone in accident and emergency departments to any asthmatic likely to need admission.

Several studies suggest that intravenous steroids confer no additional benefits over oral steroids in this situation. The main findings of four trials are reported here.

Stein & Cole [2] randomised 81 patients with acute asthma to receive either 125 mg methylprednisolone or normal saline intravenously within 30 minutes of presentation. All patients received oral prednisolone 40 mg at 6 hours and standard bronchodilator therapy. No difference was found in duration of emergency room treatment, hospitalisation or return visits.

Morell et al [3] randomised 90 patients with acute severe asthma to receive intravenous methylprednisolone 10 mg/kg four-hourly for 48 hours, or 2 mg/kg four-hourly for 48 hours, or placebo. All patients received standard bronchodilator therapy. No difference was found at 48 hours in FEV1, FVC, PEF or arterial oxygen or carbon dioxide tension.

Rodrigo & Rodrigo [4] randomised 98 patients with acute asthma to receive either intravenous hydrocortisone 500 mg or placebo in addition to bronchodilator therapy. They recorded no difference in duration of emergency room treatment or hospitalisation at six hours.

Harrison et al [5] randomised 52 patients to receive intravenous hydrocortisone 3 mg/kg bolus, 3 mg/kg six-hourly or placebo. All patients received prednisolone 45 mg orally followed by 15 mg eight-hourly plus bronchodilator therapy. There was no difference in peak flow measurements at 24 hours.

Conclusion

While there is no doubt about the effectiveness of steroids in the management of chronic asthma, there is at least a question over their usefulness in the management of acute asthma. Prednisolone is readily absorbed from the stomach and achieves peak plasma concentrations in about 15 minutes. The routine use of intravenous steroids in patients with acute asthma who can take oral steroids should be discontinued.

Dr MAC Pietroni & Dr JS Milledge
Northwick Park Hospital
Watford Rd, Harrow, Middlesex HA1 3UJ

References:

  1. British Thoracic Society. Guidelines for the management of asthma in adults:II - Acute severe asthma. Thorax 1992 47: suppl.
  2. LM Stein, RP Cole. Early administration of corticosteroid in the emergency room treatment of acute asthma. Annals of Internal Medicine 1990 112: 822-7.
  3. F Morell, R Orriols, J de Garcia, V Currull, A Pujol. Controlled trial ofintravenous corticosteroids in severe acute asthma. Thorax 1992 47: 588-91.
  4. C Rodrigo, G Rodrigo. Early administration of hydrocortisone in the emergency room treatment of acute asthma: a controlled clinical trial. Respiratory Medicine 1994 88: 755-61.
  5. BDW Harrison, GJ Hart, NJ Ali, TC Stokes, DA Vaughan, AA Robinson. Need for intravenous hydrocortisone in addition to oral prednisolone in patients admitted to hospital with severe asthma without ventilatory failure. Lancet 1986 i: 181-4.



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