Are Oral Steroids being overused for children with asthma?

Oral Corticosteroids have been shown to have definite benefit for children with moderate to severe asthma exacerbations, but no benefit and possible harm for minimal to mild exacerbations.  Recent research using data from Texas Children’s Health Plan has found very high rates of oral corticosteroid dispensing in the prior year for children with a diagnosis of asthma – close to 50% for children under 5 years, and close to 40% of children with asthma over 5 years.  There was large variation in oral corticosteroid dispensing rates by pediatrician primary care provider, but no difference in asthma hospitalization rates comparing the low prescribers to the high prescribers.

Oral corticosteroids are not appropriate for cough or wheeze that is not from asthma. Oral corticosteroids are not appropriate for mild asthma exacerbations that will most likely resolve on their own with just symptomatic therapy.  Oral corticosteroids are not appropriate if the patient has a normal oxygen saturation (≥96% on room air) and has a normal respiratory rate. Early administration of oral corticosteroids may be considered if the patient has a history of rapidly progressing life threatening asthma exacerbations. Prompt administration of oral corticosteroid medication is important for a moderate to severe asthma exacerbation with increased respiratory rate, nasal flaring, or accessory muscle use.

What is the take home message from this? Like Goldilocks and the Three Bears, don’t use too much or too little. It needs to be just right.

References:

Farber HJ, Silveira EA, Vicere DR, Kothari VD, Giardino AP. Oral Corticosteroid Prescribing for Children With Asthma in a Medicaid Managed Care Program. Pediatrics. 2017;139(5):e20164146

http://pediatrics.aappublications.org/content/early/2017/04/06/peds.2016-4146

Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2017. Avialable from http://ginasthma.org/2017-gina-report-global-strategy-for-asthma-management-and-prevention/

Asthma/Recurrent Wheezing Clinical Guideline Evidence-Based Guideline.   Texas Children’s Hospital Evidence Based Outcome Center January 2014