methylprednisolone  

Question:

What is the optimal dose of intravenous methylprednisolone for acute asthma exacerbation?

Several pharmacotherapeutic options are available to treat acute asthma exacerbations. These include high-dose, multiple-dosed, inhaled beta-2 adrenergic agonists (eg, levalbuterol and albuterol), inhaled anticholinergic agents (eg, ipratropium), fluids, and oxygen. Systemic corticosteroids are indicated in acute asthma exacerbations to decrease airway inflammation or for patients who fail to respond promptly and completely to conventional therapy.[1,2] Patients who require emergency department stabilization and/or subsequent hospitalization with a peak expiratory flow rate of < 25% of predicted should receive intravenous (IV) corticosteroids.[2]

It is conventional to use IV corticosteroids in this setting over inhaled corticosteroids; however, some investigators have shown similar results with oral steroids compared with IV steroids in adults.[3,4] Clinical results also were not different in a pediatric population given IV methylprednisolone or oral prednisone at equipotent doses.[5]

The optimal dose of IV methylprednisolone in severe acute asthma exacerbations has not been defined, but most authorities recommend 60-80 mg in 3 or 4 divided doses for 48 hours, then 30-40 mg/day until peak expiratory flow reaches 70% of personal best.[2] IV corticosteroids might be preferred over oral therapy for severe asthma exacerbations in patients in acute respiratory distress with actual or impending respiratory arrest; for patients in intensive care, when oral therapy cannot be initiated or tolerated; or when oral absorption is impaired.

In actual practice, higher doses of IV methylprednisolone may be used; however, dose-response relationships have not been identified in this setting and do not appear to confer additional clinical benefits.[6] Few studies have directly compared different doses of IV methylprednisolone for inpatient care of the patient with acute asthma. Emerman and Cydulka[7] compared 100 mg with 500 mg doses of IV methylprednisolone for acute asthma in the emergency department setting. In this study of 150 patients, there was no difference in objective outcomes between the 2 treatment groups. More recent reviews have concluded that daily systemic corticosteroid doses greater than standard doses (ie, prednisone-equivalent of 50-100 mg) provide no additional benefit.[8]

References

  1. Schreck DM. Asthma pathophysiology and evidence-based treatment of severe exacerbations. Am J Health-Syst Pharm. 2006;63(Suppl 3):S5-S13.
  2. National Institutes of Health, National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma. Full report 2007. Available at http://www.nhlbi.nih.gov/guidelines/asthma Accessed August 16, 2011.
  3. Cunnington D, Smith N, Steed K, Rosengarten P, Kelly AM, Teichtahl H. Oral versus intravenous corticosteroids in adults hospitalised with acute asthma. Pulm Pharmacol Ther. 2005;18:207-212.
  4. Ratto D, Alfaro C, Sipsey J, Glovsky MM, Sharma OP. Are intravenous corticosteroids required in status asthmaticus? JAMA. 1988;260:527-529.
  5. Becker JM, Arora A, Scarfone RJ, et al. Oral versus intravenous corticosteroids in children hospitalized with asthma. J Allergy Clin Immunol. 1999;103:586-590.
  6. McFadden ER Jr. Acute severe asthma. Am J Respir Crit Care Med. 2003;168:740-759.
  7. Emerman CL, Cydulka RK. A randomized comparison of 100-mg vs 500-mg dose of methylprednisolone in the treatment of acute asthma. Chest. 1995;107:1559-1563.
  8. Krishnan JA, Davis SQ, Naureckas ET, Gibson P, Rowe BH. An umbrella review: corticosteroid therapy for adults with acute asthma. Am J Med. 2009;122:977-991.

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