What is the evidence for using steroids in viral-induced wheeze?

Evidence for Steroids in Viral-Induced Wheeze

Corticosteroids should not be used routinely in the management of viral-induced wheeze in children, as there is insufficient evidence to support their effectiveness. 1

Current Evidence on Corticosteroid Use

Systemic Corticosteroids

• The American Academy of Pediatrics states that corticosteroid medications should not be used routinely in the management of bronchiolitis (recommendation: evidence level B) 1
• A Cochrane database review of 13 studies with 1198 patients showed no significant decrease in length of stay with systemic glucocorticoids compared to placebo 1
• A randomized controlled trial of 700 preschool children with acute virus-induced wheezing found that oral prednisolone was not superior to placebo for reducing duration of hospitalization or improving secondary outcomes 2
• A study by Panickar et al. (2009) showed no significant difference between prednisolone and placebo groups in duration of hospitalization (13.9 hours vs. 11.0 hours) 2

Inhaled Corticosteroids

• The Cochrane review on inhaled steroids for episodic viral wheeze identified five randomized controlled trials, with mixed results 3
• High-dose episodic inhaled corticosteroids showed some benefit in reducing requirement for oral corticosteroids (RR=0.53,95% CI: 0.27,1.04) and were preferred by parents over placebo 3
• Maintenance low-dose inhaled corticosteroids did not show any clear reduction over placebo in episodes requiring oral corticosteroids (RR=0.82,95% CI: 0.23,2.90) 3
• Two available studies evaluating inhaled corticosteroids in bronchiolitis showed no benefit in the course of acute disease 1

Special Considerations

Subgroups That May Respond

• One study suggested that prednisolone might be effective specifically in children with picornavirus-induced wheezing (particularly enterovirus), reducing time until ready for discharge (12 vs. 24 hours, p=0.0022) 4
• However, this finding requires confirmation in prospectively designed clinical trials 4

Parent-Initiated Treatment

• A randomized controlled trial of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years found no clear benefit compared to placebo 5
• This lack of benefit was consistent even in children with above-average systemic eosinophil priming 5

Potential Risks of Corticosteroid Use

• Documented side effects of steroid therapy include:
  • Increased risk of infection
  • Impaired wound healing
  • Hypertension
  • Mood disorders
  • Ophthalmologic disorders
  • Skin disorders 1
• Inhaled corticosteroids can cause oral candidiasis and pharyngitis in a dose-dependent fashion 1

Alternative Treatments

• For mild episodic viral wheeze, alternatives to corticosteroids include:
  • Cromolyn (nebulizer preferred)
  • Leukotriene receptor antagonists 1
• However, a Cochrane review found little evidence of significant clinical benefit for leukotriene receptor antagonists in episodic viral wheeze 6

Clinical Approach to Viral-Induced Wheeze

1. Diagnosis: Differentiate viral-induced wheeze from persistent atopic asthma

   • Viral-induced wheeze is characterized by wheeze in association with coryzal symptoms with minimal intercurrent lower respiratory tract symptoms 3
   • Not all wheezes and coughs are caused by asthma; consider other conditions 1

2. Management:

   • Focus on symptomatic relief rather than corticosteroids
   • Consider bronchodilator trial in office/clinic setting using albuterol/salbutamol rather than epinephrine 1
   • Monitor parameters including improvements in wheezing, respiratory rate, respiratory effort, and oxygen saturation 1

3. When to Consider Corticosteroids:

   • Only in select cases with clear likelihood of benefit 1
   • High-dose episodic inhaled corticosteroids might be considered for children with more severe episodes 3

Common Pitfalls

• Overuse of corticosteroids in viral-induced wheeze despite limited evidence of benefit
• Failure to distinguish between viral-induced wheeze and atopic asthma
• Not recognizing that viral-induced wheeze is often self-limiting
• Exposing children to unnecessary medication with potential adverse effects

In conclusion, the current evidence does not support the routine use of systemic corticosteroids in children with viral-induced wheeze. While high-dose episodic inhaled corticosteroids may provide some benefit in select cases, the overall evidence suggests that the risks of corticosteroid therapy generally outweigh the benefits in this condition.