For a moderate pediatric asthma exacerbation, is Decadron (dexamethasone) or prednisone preferred?

Dexamethasone vs. Prednisone for Moderate Pediatric Asthma Exacerbations

Dexamethasone is preferred over prednisone for moderate pediatric asthma exacerbations due to its comparable efficacy with improved compliance, reduced vomiting, and shorter course of treatment. 1

Comparative Efficacy

• Dexamethasone (1-2 days) is as effective as a 5-day course of prednisone/prednisolone in treating moderate pediatric asthma exacerbations, with no significant difference in relapse rates at 5 days, 10-14 days, or 30 days 1
• Meta-analysis of multiple randomized controlled trials shows equivalent outcomes between dexamethasone and prednisone regimens for pediatric asthma exacerbations 2
• Two doses of oral dexamethasone (0.6 mg/kg/dose) demonstrated similar efficacy to a 5-day course of oral prednisone (2 mg/kg/day) in preventing relapse for pediatric asthma exacerbations 3

Advantages of Dexamethasone

• Dexamethasone causes significantly less vomiting both in the emergency department (RR 0.29,95% CI 0.12-0.69) and at home (RR 0.32,95% CI 0.14-0.74) compared to prednisone 1
• The shorter treatment course (1-2 days vs. 5 days) improves medication compliance, which is particularly important in pediatric patients 4
• Dexamethasone has a longer half-life (36-72 hours) compared to prednisone (12-36 hours), allowing for fewer doses while maintaining therapeutic effect 4
• Better palatability of dexamethasone contributes to improved adherence in children 2

Current Practice Patterns

• Pediatric emergency medicine specialists have increasingly adopted dexamethasone as their preferred treatment (59% of program directors), while other specialties including pulmonology (89%) and allergy/immunology (93%) still favor prednisone 5
• The most common dexamethasone dosing is 0.6 mg/kg with a maximum dose of 10 mg 5

Treatment Algorithm for Moderate Pediatric Asthma Exacerbations

1. First-line treatment: Dexamethasone 0.6 mg/kg (maximum 10 mg) given as either:

   • Single dose, OR
   • Two doses given 24 hours apart 1, 5

2. Alternative treatment: If dexamethasone is unavailable or contraindicated:

   • Prednisone/prednisolone 2 mg/kg/day (maximum 60 mg) for 5 days 3

Important Considerations

• For severe asthma exacerbations, systemic corticosteroids are essential, but the evidence comparing dexamethasone and prednisone is primarily for mild-to-moderate exacerbations 2
• Consider patient-specific factors such as history of medication adherence issues, which would favor the shorter dexamethasone course 4
• While most research has been conducted in emergency department settings, the findings are applicable to outpatient management of moderate asthma exacerbations 2