Original Article
Inhaled Corticosteroids in Acute Asthma: A Systemic Review and Meta-Analysis

https://doi.org/10.1016/j.jaip.2019.08.051Get rights and content

Background

Asthma exacerbations are a common and important cause of attendance at emergency departments (ED) and subsequent hospital admissions. Despite previous reviews reporting that in acute settings the risk of hospital admission is reduced with the use of high doses of inhaled corticosteroids (ICS), this evidence has not changed clinical practice.

Objective

To estimate the efficacy of ICS in the treatment of acute asthma in ED.

Methods

Randomized controlled trials were identified using PubMed, The Cochrane Library, and EMBASE. The primary outcome was hospital admission rates. The primary comparison was between administration of ICS in addition to systemic corticosteroids (SCS) and to SCS alone. Secondary comparisons were ICS alone compared with SCS alone and ICS compared with placebo.

Results

There were 25 studies involving 2733 participants. For the primary comparison, ICS in addition to SCS reduced the risk of hospital admission compared with SCS; fixed-effects odds ratio (95% confidence interval) 0.73 (0.57-0.94). Lung function was poorly reported. There was moderate evidence of an improvement in clinical scores and vital signs with ICS in addition to SCS. Relatively few studies reported adverse events.

Conclusion

There is moderate evidence that high doses of ICS, in addition to SCS, reduce the risk of hospital admission in ED treatment of moderate-to-severe asthma exacerbations. Further research is required to determine their optimal role in both ED and outpatient settings.

Section snippets

Search strategy

This review is registered with PROSPERO (registration number: CRD42018111273). The review protocol can be found at https://www.crd.york.ac.uk/PROSPEROFILES/111273_PROTOCOL_20190110.pdf.

The literature search was undertaken using the following electronic bibliographic databases: PubMed, The Cochrane Library, EMBASE, and clinicaltrials.gov.

The search terms were asthma AND (emergency or acute or severe or exacerbation or hospital or intensive or admit or admission or discharge) AND (steroid or

Description of studies

The search identified 4612 papers, of which 25 papers9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 were included in the analyses, which involved 2733 participants. The flow of studies is shown in Figure 1. No additional papers were identified from the reference lists of the included papers. All studies were randomized controlled trials. Five new studies had been published since the last updated Cochrane review.7 The details of the identified

Discussion

The systematic review and meta-analysis found that in patients presenting to ED with an exacerbation of asthma, the addition of ICS to SCS reduces the risk of admission to hospital. The magnitude of the effect was of clinical importance with a fixed-effects OR for admission of 0.73, although there was some evidence of heterogeneity and the CIs were wide. Although lung function was poorly reported, there was supporting evidence of improvement in clinical scores and vital signs. Although the

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    The Medical Research Institute of New Zealand (MRINZ) is supported by Health Research Council of New Zealand Independent Research Organisation funding.

    Conflicts of interest: R. Beasley declares the conflict of the MRINZ receiving funding from AstraZeneca, Genentech, and GSK, outside of the submitted work. The rest of the authors declare that they have no relevant conflicts of interest.

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