For a child with an asthma exacerbation, is dexamethasone or Solu-M (methylprednisolone) better?

From the Guidelines

For a child with an asthma exacerbation, dexamethasone is the preferred treatment option due to its effectiveness as a single dose, improving adherence and reducing the need for multiple days of treatment. When considering the treatment of asthma exacerbations, it is essential to prioritize morbidity, mortality, and quality of life as the outcome. The provided evidence from the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations 1 supports the use of dexamethasone as a single dose of 0.6 mg/kg (maximum 16 mg) orally or intramuscularly. This regimen has been shown to be effective in reducing airway inflammation and improving symptoms, with the added benefit of not requiring multiple days of treatment.

Some key points to consider when treating asthma exacerbations in children include:

• The choice of medication depends on the severity of the exacerbation, the treatment setting, and considerations about adherence to the medication regimen
• Dexamethasone has a longer half-life (36-72 hours) compared to methylprednisolone (12-36 hours), making it effective as a single dose
• Methylprednisolone can be administered intravenously at 1-2 mg/kg/day divided every 6 hours in the hospital setting, or prednisone/prednisolone can be given orally at 1-2 mg/kg/day (maximum 60 mg) for 3-5 days as an outpatient
• There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 1

In terms of specific dosing, the evidence suggests that dexamethasone can be given as a single dose, while methylprednisolone may require multiple doses. The dosing for methylprednisolone is 1-2 mg/kg/day (maximum 60 mg) for 3-10 days, as outlined in the NAEPP Expert Panel Report 1. However, the most recent and highest quality study 1 supports the use of dexamethasone as a single dose, making it a more convenient and effective treatment option for children with asthma exacerbations.

From the FDA Drug Label

In pediatric patients, the initial dose of methylprednisolone may vary depending on the specific disease entity being treated. The National Heart, Lung, and Blood Institute (NHLBI) recommended dosing for systemic prednisone, prednisolone, or methylprednisolone in pediatric patients whose asthma is uncontrolled by inhaled corticosteroids and long-acting bronchodilators is 1 mg/kg/day to 2 mg/kg/day in single or divided doses

The FDA drug label does not compare the effectiveness of dexamethasone and methylprednisolone (Solu-M) for a child with an asthma exacerbation.

• The label provides dosing information for methylprednisolone in pediatric patients with asthma, but does not mention dexamethasone in this context.
• The label does provide equivalent milligram dosages of various glucocorticoids, including dexamethasone and methylprednisolone, but this information is not specific to the treatment of asthma exacerbations in children 2.

From the Research

Comparison of Dexamethasone and Prednisone for Asthma Exacerbation in Children

• Dexamethasone has been shown to be noninferior to prednisone in the treatment of acute asthma exacerbations in children, with a single dose of dexamethasone (0.3 mg/kg) being as effective as a 3-day course of prednisolone (1 mg/kg per day) 3.
• A meta-analysis of 10 randomized trials found that dexamethasone might be equally effective in reducing hospitalizations and revisits, and has probably fewer adverse effects than other corticosteroids 4.
• A retrospective cohort study found that the initial steroid choice (dexamethasone versus prednisone) was not associated with 30-day reutilization after hospitalization for an asthma exacerbation 5.
• Another study found that dexamethasone is less commonly used in the pediatric emergency department for asthmatic patients triaged as most urgent, and that triage acuity and level of training were associated with single-dose treatment of asthma in those receiving dexamethasone 6.
• A survey of providers found that one third of providers are using dexamethasone, while just over half of providers are prescribing a 5-day prednisone course, with pediatric emergency medicine fellowship directors demonstrating a preference for dexamethasone 7.

Efficacy and Safety of Dexamethasone

• Dexamethasone has been shown to have a longer half-life and has been used safely in other acute pediatric conditions 3.
• A study found that 14 patients vomited at least one dose of prednisolone compared to no patients in the dexamethasone group, suggesting that dexamethasone may have a better safety profile 3.
• However, another study found that 16 children (13.1%) in the dexamethasone group received further systemic steroids within 14 days after trial enrollment, compared to 5 (4.2%) in the prednisolone group, suggesting that dexamethasone may not be as effective in preventing relapse 3.

Clinical Practice Patterns

• A study found that pediatric emergency medicine fellowship directors demonstrated a preference for dexamethasone, while emergency medicine, pediatric pulmonology, and allergy and immunology program directors favored prednisone 7.
• Another study found that dexamethasone is increasingly used for the management of children hospitalized with asthma, yet data regarding its effectiveness in children with asthma exacerbation severe enough to require hospitalization are limited 5.