RAPID IMPROVEMENT OF PEAK FLOW IN ASTHMATIC PATIENTS TREATED WITH PARENTERAL METHYLPREDNISOLONE IN THE EMERGENCY DEPARTMENT: A RANDOMIZED CONTROLLED STUDY

Lin RY, et al. Ann Emerg Med May 1999;33:487-494.

BACKGROUND: Many experts and texts state that when corticosteroids are used in the treatment of an acute asthma exacerbation, the onset of beneficial effects occurs only after several hours. The goal of this randomized, double-blind, placebo-controlled trial, from St. Vincent's Hospital in New York City, was to test the hypothesis that intravenous methylprednisolone improves airflow within 2 hours of administration.

METHODS: Adult asthmatic ED patients with peak expiratory flow rates (PEFR) < 50% predicted after one albuterol nebulizer treatment (2.5 mg) were eligible. Exclusion criteria included a smoking history of 20 pack-years or more. After the initial albuterol, subjects received either 125-mg methylprednisolone IV bolus or placebo, and then identical regimens of oxygen and nebulized albuterol and ipratropium. PEFRs were measured at enrollment and hourly for the first 2 hours.

RESULTS: 56 patients were studied. The methylprednisolone group (N=30) showed significantly greater improvement in mean PEFR and percent predicted PEFR and 1 and 2 hours compared with the placebo group (N=26). There was a trend towards decreased hospital admissions in the treatment group that did not reach statistical significance.

CONCLUSION: These results suggest that use of corticosteroids should be considered early in the treatment of acute asthma exacerbations that are severe or do not respond to initial therapy with bronchodilators. Corticosteroids seem to improve respiratory status in these patients within the initial 2 hours of treatment.

COMMENTS: There are several points of contention in this study. The placebo group also had a longer median duration of symptoms (60 vs 36 hrs), which has been demonstrated to have a worse prognosis. The better performance was trivial when absolute values were compared. There was no mention of clinical improvement, ie how the patient felt. There was no statistical difference in rate of admission. In fact, one of the admitted patients in the placebo group was admitted for abdominal pain. The dose of albuterol was relatively small, only 2.5 mg. And finally, there was NO comparison to PO steroids.