Doses of corticosteroids in hospitalised patients with acute severe asthma: A systematic review

The optimal dose and route of administration of corticosteroids in acute asthma continues to be debated. Aim: To conduct a systematic review of randomised controlled trials of systemic corticosteroid therapy in adults hospitalised with acute severe asthma to determine whether higher doses of corticosteroids are more efficacious than low doses. Methods: Following the guidelines of the Cochrane Collaboration, a protocol was developed including a comprehensive search strategy, inclusion criteria, methods for quality assessment & data extraction and proposed a priori subgroup and sensitivity analyses. For the purposes of this review, 3 broad categories of corticosteroid dose (equivalent dose of methyl-prednisolone in 24 hours) were defined in advance: low dose (< 80mg), medium dose (80mg to 360mg) and high dose (>360mg). The primary outcome measure was pulmonary function, but all reported outcomes were considered. The metaanalysis was performed using random effects models in RevMan 3.1. Results: Of the 21 articles selected from the search for possible inclusion, 9 trials were included in the review. However only 6 trials provided sufficient data for the quantitative analysis. There were no statistically significant differences detected in FEVi (% predicted) between treatment groups for any of the comparisons after 24, 48 or 72 hours. At 48 hours, the weighted mean difference was -2.2 (95% Confidence Interval -12.1 to + 7.7) for the low versus moderate dose comparison, -2.7 (95% Cl - 9.0 to 3.6) for the moderate versus high dose comparison and -1.0 (95% Cl -14.5 to + 12.6) for the low versus high dose comparison. Conclusions: In adults with acute severe asthma requiring hospital admission, treatment with low dose corticosteroid (< 80mg methyl-prednisolone equivalent per day) appears as efficacious as medium or high doses.