IM vs. Oral Methylprednisolone for Asthma

[Seaglass]

Randomized Clinical Trial of Intramuscular vs Oral Methylprednisolone in the Treatment of Asthma Exacerbations Following Discharge from an Emergency Department

OBJECTIVE: To compare the efficacy of long-acting IM methylprednisolone to tapering oral methylprednisolone in adult asthmatic patients discharged from the emergency department (ED). METHODS: Randomized, double-blind, placebo-controlled trial of a single IM dose of 160 mg depot methylprednisolone vs 8-day tapering of a total dose of 160 mg oral methylprednisolone in adult asthmatic patients (age range, 18 to 45 years) who were discharged from the ED following standardized treatment for an acute exacerbation. The primary end point was relapse, which was defined as the need to seek unscheduled care at a doctor's office, clinic, or ED for symptoms of persistent or worsening asthma within 10 days of ED discharge. RESULTS: Of 190 patients enrolled into the study, 180 completed the study and the follow-up at 10 days (96%). The relapse rate was nearly identical for the two treatment groups (IM administration, 14.1% [13 of 92 patients]; oral administration, 13.6% [12 of 88 patients]; difference, 0.5% [95% confidence interval, - 9.6 to 10.6%]). CONCLUSIONS: Single-dose IM methylprednisolone administered to adult asthmatic patients at ED discharge appears to be a viable therapeutic alternative to a course of oral methylprednisolone. Clinicians may choose to base the route of administration of corticosteroids on concerns about nonadherence to therapy or on the ability of a patient to afford a prescription for outpatient medication.


I'm wondering if the bounceback rate will be any better for those self-pay/non-compliant patients.

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[southerndoc]

I'm wondering if the bounceback rate will be any better for those self-pay/non-compliant patients.

We actually have 5-day burst packs of prednisone that we give out in the ED if a patient is thought to be unable to afford the meds or unlikely to buy the meds.

 

[Freeeedom!]

Much of it certainly depends on the acuity of the patient...if the patient is bad, they deserve the IV full of loveable steroid (regardless if the time to onset is significant)...they get an IV and I am using it.
If the patient is going home, compliance is a huge issue with oral prednisone (which is what I give), often times I use IM Dex one time dose only.

 

[Jeff698]

Much of it certainly depends on the acuity of the patient...if the patient is bad, they deserve the IV full of loveable steroid (regardless if the time to onset is significant)...they get an IV and I am using it.
If the patient is going home, compliance is a huge issue with oral prednisone (which is what I give), often times I use IM Dex one time dose only.

Interesting point. My understanding is that the route truly is irrelevant except for logistics.

I'm trying to do a study looking at prehospital MP use in these patients to see if it makes any difference. The route question came up when we were doing the design.

Take care,
Jeff

 

[docB]

Is anyone else having a shortage of solumedrol? I can't get it at my hospitals except for spinal cord injury. For injectable they're making us use dex instead so I am practically only using oral prednisone.

 

[Seaglass]

I just heard within the last two weeks that the shortage is over and that solumedrol is flowing plentifully again.

 

[drpcb]

Depot-medrol is very different than IM dex or IM MP or any other ED drugs since it has a 1/2 life of about a week. It is unusual however to get it on your ED formulary, because ER nurses are unfamiliar with it, and likely to give it intravenously with potentially catastrophic outcomes. (strokes, embolic complications, etc.) I used to use it regularly in the clinic, where the Nurse assistants couldn't screw it up too badly since they didn't place IV's. In that setting, the biggest disaster was trying to explain to the 55 year old man with RA why my assistant just injected him with a long acting birth control (Depot Provera) instead of the Depot Medrol that I had ordered. You would be amazed at how similar the boxes and bottles look!

If we had Depot medrol in the ED I would probably use it for my asthma/COPD patients.

 

[drpcb]

Interesting point. My understanding is that the route truly is irrelevant except for logistics.

I'm trying to do a study looking at prehospital MP use in these patients to see if it makes any difference. The route question came up when we were doing the design.

Take care,
Jeff

If you are trying to detect a small benefit from PH administration, I would strongly suggest nebulized steroids. Dexamethasone and budesonide are well studied in nebulized forms. If you see more sick patients, and you want to reduce delays, nebulized is the fastest. It has been shown to be superior to oral (Effectiveness of oral or nebulized dexamethasone for children with mild croup Arch Pediatr Adolesc Med. 2001 Dec;155(12):1340-5.) You just might show an improved outcome, considering the delays in most ED's getting steroids on board.