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Steroid Storms: Controversies and Considerations
in PEM
Kimball Prentiss, MD, FAAPDivision of Pediatric Emergency Medicine
September 19, 2018CCEM Conference, Northampton
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Objectives
• Develop an understanding of the evidence for the use for or against steroids in common, reasonably common, and/or high-risk clinical conditions within pediatric emergency medicine
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OUTLINE
• asthma• bronchiolitis • croup• anaphylaxis• pharyngitis• meningitis• hsp• cautionary tales• crystallize
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ABCs
• asthma• bronchiolitis• croup
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ABCs
• asthma?• bronchiolitis• croup
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ABCs
• asthma YES• bronchiolitis• croup
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ABCs
• asthma YES • dex vs methylprednisolone? • 1 dose vs 3 vs 5? • inhaled corticosteroids (ICS)?
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ASTHMA: Where does the evidence lead us?
• National Heart, Lung, Blood Institute of NIH guidelines last updated in 2007 • prednisone PO 1-2 mg/kg/day (max 60 mg/day)
• What about Dexamethasone?
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DEX: Where does the evidence lead us?
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DEX: Where does the evidence lead us?
• comparable efficacy between 1-2 dose dex and 3-5 doses oral pred
• no difference in return visits or readmissions • less vomiting • improved compliance
• Keeney G, Gray M, Morrison A et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2014;133(3):493-499.
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3 vs 5: Where does the evidence lead us?
• Chang AB, Clar R, Sloots TP, Stone DG et al. A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalized: a randomized controlled trial. Med J Aust. 2008;189(6):306-10.
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ICS: Where does the evidence lead us?
• Sampayo EM, Mazer M, Camp EA and Zorc, JJ. Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial. Ann Emerg Med. 2017;70(3):331-337. Edmonds
• Edmonds ML, Milan SJ, Camarga CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev. 2012 Dec;12:CD002308.
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ABCs
• asthma• bronchiolitis?• croup
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ABCs
• asthma• bronchiolitis NO• croup
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BRONCHIOLITIS: Where does the evidence lead us?
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BRONCHIOLITIS: Where does the evidence lead us?
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BRONCHIOLITIS: Where does the evidence lead us?
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ABCs
• asthma • bronchiolitis • croup?
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ABCs
• asthma• bronchiolitis• croup?• mild?• moderate?• severe?
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STEROID?
YES
YES
YES
?
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MILD CROUP: Where does the evidence lead us?
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ABCs
• HOW MUCH? • low-dose(0.15 mg/kg) vs high (0.6 mg/kg)
• HOW? • PO vs NEB vs IM
• WHICH? • dex vs pred
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CROUP: Low-dose vs high-dose dex
• low-dose as efficacious as high-dose• symptoms scores and return visits
• fewer side effects
• Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emerg Med Australas. 2007;19(1):51-58
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CROUP: route
• equivalence between routes• oral preferred
• Russell K, Weibe N, Saenz A et al. Glucocorticoids for croup. Cochrane Database Systemic Review. 2004;1: CD001955 (Systematic Review; 31 studies, 3767 patients)
• Geelhold GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol. 1995;20(6):355-361
• Klassen TP, Craig WR, Moher S, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA. 1998;279(20):1629-1632.
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• Fifoot AA, Ting JY• RDBPCT 2007• single dose oral prednisolone (1 mg/kg) as efficacious as
single dose low-dose dex (0.15 mg/kg)• Sparrow A, Geelhoed G
• RDB controlled equivalence trial 2006• single pred less effective than single dose dex in reducing
unscheduled repeat visits mild-moderate croup• Garrbutt et al 2013
• pred 2 mg/kg/d x 3 days vs dex 0.6 mg/kg (+2 placebo)• no differences (unscheduled visit, duration, disturbed sleep)
CROUP: dex vs pred
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CASE 1
• 4 year old F BIBEMS with drooling, urticaria, wheeze, vomiting and hypotension.
• Epi • Would you give steroids?• I would
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CASE 2
• 3 yo F BIBEMS with urticaria and drooling
• Steroids?
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ANAPHYLAXIS: where does the evidence lead us?
• Lewis et al • no statistical difference in the corticosteroid treated
groups re uniphasic vs biphasic reactions • Lee et al
• no evidence to support corticosteroid use to decrease biphasic reactions
• 2012 Cochrane review • lack of adequate randomized controlled trials (1956-2011)
unable to make any recommendations for the use of glucocorticoids in anaphylaxis
• Gruneau et al • no difference in bounce back within 7 days or biphasic
NO EVIDENCE
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CASE 3
• 13 yo GAS+ on day 1 Amoxicillin, NSAID RTC
• ED visit for inability to take PO due to pain
• No drooling • No trismus • Kissing tonsils, exudative, no asymmetry • Steroids?
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PHARYNGITIS: where does the evidence lead us?
REDUCE DURATION OF PAIN: insuff icient ev idence to endorse routine use
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CASE 4
• 6 month immunized infant with fever• bulging fontanelle, vomiting, paradoxical
irritability• wbc 25, crp 7• LP results pending• steroids?
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MENINGITIS: where does the evidence lead us?
• AAP and IDSA • IF BACTERIAL and > 6 weeks• dex 0.15 mg/kg IV every 6
hours• best before antibiotics• at least concurrent
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CASE 5
• 4 yo M dx with HSP by pcp 2 days ago• unable to ambulate • intermittent severe abdominal pain• tea colored urine• steroids?• for which indication?
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HSP: where does the evidence lead us?
• Weiss et al 2007• 15 articles
• Cochrane Review 2009• 10 studies
• Conflicting evidence• KDIGO • YES, if nephritis• NO for prevention
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CAUTIONARY TALES?
• cerebral thrombosis• gi bleeding• growth restriction• bacterial tracheitis• behavioral changes
NO EVIDENCE
• Thabet A, Greenfield T, Cantor R. Corticosteroid Use In Management of Pediatric Emergency Conditions. Pediatric Emergency Medicine Practice: An evidence-based approach to pediatric emergency medicine. 2018;15(3):1-15.
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CAUTIONARY TALES?
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SUMMARY
• asthma• bronchiolitis • croup• anaphylaxis• pharyngitis• meningitis• hsp
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SUMMARY
NO
bronchiolitis
CONSIDER anaphylaxis
pharyngitis
meningitis
hsp
YES asthma
croup
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References
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References• Thabet A, Greenfield T, Cantor R. Corticosteroid Use In Management of Pediatric Emergency Conditions. Pediatric
Emergency Medicine Practice: An evidence-based approach to pediatric emergency medicine. 2018;15(3):1-15.• Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134:e1474-e1502.
• A randomized trial of a single dose of oral dexamethasone for mild croup. N Eng J Med. 2004. 351(13):1306-13.• US Department of Health and Human Services, National Hear, Lung, and Blood Institute, National Asthma
Education and Prevention Program. Expert panel report 3:guidelines for the diagnosis and management of asthma 2007, available at:https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf Accessed February 15, 2018 (Guidelines)
• Sampayo EM, Mazer M, Camp EA and Zorc, JJ. Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial. Ann Emerg Med. 2017;70(3):331-337.
• Keeney G, Gray M, Morrison A et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2014;133(3):493-499.
• Edmonds ML< Milan SJ, Camarga CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev. 2012 Dec;12:CD002308.
• Chang AB, Clar R, Sloots TP, Stone DG et al. A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalized: a randomized controlled trial. Med J Aust. 2008;189(6):306-10.
• Russell K, Weibe N, Saenz A et al. Glucocorticoids for croup. Cochrane Database Systemic Review. 2004;1: CD001955 (Systematic Review; 31 studies, 3767 patients)
• Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emerg Med Australas. 2007;19(1):51-58.
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References• Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in
the treatment of croup: a randomized, double-blinded clinical trial. Emerg Med Australas. 2007;19(1):51-58.
• Alesehr A, ALmegamas, T, Hammdi, A. Efficacy of a small dose of oral dexamethasone in croup. Biomedical Research. 2005;16(1):65-72.
• Geelhold GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol. 1995;20(6):355-361
• Klassen TP, Craig WR, Moher S, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA. 1998;279(20):1629-1632.
• Geelhold GC. Budesoide offers no advantage when added to oral dexamethasone in the treatment of croup. Pediatric Emerg Care. 2005;21(6):359-362 Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015(9):CD004405
• Bernardo WM, Aires FT, Sa FP. Effectiveness of the association of dexamethasone with antibiotic therapy in pediatric patients with bacterial meningitis. Rev Assoc Med Bras. 2012;58(3):319-322.
• Weiss PF, Feinstein JA, Luan X, et al. Effects of corticosteroid on Henoch-Schonlein purpura: a systematic review. Pediatrics. 2007;120(5):1079-1087.
• Chartapisak W ,Opastirakul S, Hodson EM et al. Interventions for preventing and treating kidney disease in Henoch-Schonlein Purpura. Cochrane Database Syst Rev. 2009(3):CD005128.