Steroid Storms: Controversies and Considerations

in PEM

Kimball Prentiss, MD, FAAPDivision of Pediatric Emergency Medicine

September 19, 2018CCEM Conference, Northampton

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

OUTLINE

• asthma• bronchiolitis • croup• anaphylaxis• pharyngitis• meningitis• hsp• cautionary tales• crystallize

ABCs

• asthma• bronchiolitis• croup

ABCs

• asthma?• bronchiolitis• croup

ABCs

• asthma YES• bronchiolitis• croup

ABCs

• asthma YES • dex vs methylprednisolone? • 1 dose vs 3 vs 5? • inhaled corticosteroids (ICS)?

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?

DEX: Where does the evidence lead us?

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.

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.

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.

ABCs

• asthma• bronchiolitis?• croup

ABCs

• asthma• bronchiolitis NO• croup

BRONCHIOLITIS: Where does the evidence lead us?

BRONCHIOLITIS: Where does the evidence lead us?

BRONCHIOLITIS: Where does the evidence lead us?

ABCs

• asthma • bronchiolitis • croup?

ABCs

• asthma• bronchiolitis• croup?• mild?• moderate?• severe?

STEROID?

YES

YES

YES

?

MILD CROUP: Where does the evidence lead us?

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

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

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.

• 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

CASE 1

• 4 year old F BIBEMS with drooling, urticaria, wheeze, vomiting and hypotension.

• Epi • Would you give steroids?• I would

CASE 2

• 3 yo F BIBEMS with urticaria and drooling

• Steroids?

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

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?

PHARYNGITIS: where does the evidence lead us?

REDUCE DURATION OF PAIN: insuff icient ev idence to endorse routine use

CASE 4

• 6 month immunized infant with fever• bulging fontanelle, vomiting, paradoxical

irritability• wbc 25, crp 7• LP results pending• steroids?

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

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?

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

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.

CAUTIONARY TALES?

SUMMARY

• asthma• bronchiolitis • croup• anaphylaxis• pharyngitis• meningitis• hsp

SUMMARY

NO

bronchiolitis

CONSIDER anaphylaxis

pharyngitis

meningitis

hsp

YES asthma

croup

References

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.

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.