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Am Fam Physician. 2003;67(5):1107

Current guidelines for the treatment of severe asthma exacerbations that require hospitalization call for the use of systemic corticosteroids. The use of inhaled corticosteroids in emergency department treatment of asthma has been examined and has been proved effective. The use of inhaled corticosteroids could reduce the need for systemic corticosteroids and the side effects of these medications. Lee-Wong and associates hypothesized that the use of high-dosage, inhaled corticosteroids after an initial period of intravenous corticosteroids in hospitalized asthma patients could be as well tolerated and effective as oral corticosteroids.

The study was a randomized, double-blind, placebo-controlled trial of adult patients with severe asthma exacerbation who were admitted to the hospital for treatment. Admitted patients met criteria for hospitalization, and the decision to admit was made by a physician who was not involved in the study. All patients were treated with inhaled beta agonists every four hours as needed and with 40 mg of intravenous methylprednisolone every six hours for 48 hours. Participants were randomized to receive eight puffs of flunisolide (250 mcg per actuation) via a spacer twice daily or placebo. This therapy was initiated within 12 hours of admission. After 48 hours, the intravenous corticosteroid was discontinued, and patients began a course of therapy with oral prednisone or placebo. Patients who had received flunisolide were given placebo instead of prednisone. A follow-up visit was scheduled on day 7 of the study. Outcomes, which were measured on days 1 and 7, included peak expiratory flow rates, forced expiratory volume in one second (FEV1), and symptom scores. Secondary outcome measures included hospital readmissions, emergency department revisits, and length of hospital stay.

There was no difference in demographics or baseline pulmonary studies between the group that received inhaled corticosteroids and the group that received oral prednisone. The results of improved peak expiratory flow rates and FEV1 were similar between the two groups. In addition, symptom scores were improved in both groups, with no difference noted. There were no hospital readmissions in either treatment group, and there was no difference between the groups with regard to length of hospital stay.

The authors conclude that high-dosage inhaled corticosteroids are as effective as systemic corticosteroids in the treatment of patients with severe asthma. The use of inhaled corticosteroids can reduce the adverse effects of systemic corticosteroids. In addition, the use of high-dosage inhaled corticosteroids appears to be well tolerated when delivered via a spacer unit.

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