High-Dose Inhaled Fluticasone Does Not Replace Oral Prednisolone in Children With Mild to Moderate Acute Asthma

Schuh S, Dick PT, Stephens D, et al. Pediatrics. 2006;118:644–650 PURPOSE OF THE STUDY. To evaluate whether there is a significant difference in the degree of impairment in forced expiratory volume at 1 second (FEV1) in children with mild-to-moderate acute asthma treated with either inhaled fluticasone or oral prednisolone. STUDY POPULATION. Sixty-nine children aged 5 to 17 years with a previous history of wheezing who presented to a tertiary care pediatric emergency department (ED) with acute asthma and an FEV1 between 50% and 79% predicted. METHODS. This randomized, double-blind, double-dummy trial randomly assigned patients to receive either 2 mg of fluticasone via metered-dose inhaler (MDI) in the ED along with 500 μg of fluticasone via Diskus twice daily for 5 days (n = 35) or 2 mg/kg oral prednisolone in the ED along with 1 mg/kg prednisolone once daily for 5 days (n = 34). All children received scheduled, nebulized albuterol and ipratropium bromide in the ED and were given scheduled salmeterol and rescue albuterol on ED discharge. FEV1 was measured at baseline, 4 hours, and 48 hours. RESULTS. At 4 hours, the patients in the prednisolone group had a significantly greater increase in FEV1 (29.8% ± 15.5%) compared with those in the fluticasone group (19.1% ± 12.7%; P = .001). By 48 hours, the difference in FEV1 between the groups was no longer statistically significant. In addition, the number of unscheduled asthma visits by 48 hours after ED discharge was significantly greater in the fluticasone group (4 of 32) than the prednisolone group (0 of 34). CONCLUSIONS. Children with mild-to-moderate acute asthma improve faster on oral prednisolone than inhaled fluticasone. REVIEWER COMMENTS. Systemic corticosteroids are both historically and currently the mainstay treatment for acute asthma, given their ability to reduce hospitalizations, decrease relapses, regain asthma control, and improve lung function. However, the risks associated with the frequent use of oral corticosteroids have led researchers to search for an alternative treatment for acute asthma. Although previous studies have shown oral corticosteroids to be superior to inhaled steroids in severe acute asthma, the question remains as to whether inhaled corticosteroids could be used in mild and moderate asthma exacerbations. This study addressed this question and determined that oral corticosteroids are superior to inhaled steroids, even for mild exacerbations of asthma, in regard to relapse rate