Question re: dexamethasone for asthma exacerbations

[toshimonkey]

Hi, I'm not sure where to go for this but thought someone in this forum could direct me. I am on rotations at a children's hospital and was tasked with finding out what other hospitals are doing for children who come in for asthma exacerbations. At our hospital based upon the severity of exacerbation, we give 2 doses of dexamethasone separated by 24-36 hours. Most of the time they are discharged with an outpatient script for the second dose, but a lot of the time they don't get the Rx filled and end up being admitted again at some point. My preceptor wanted to see if other hospitals do something different in order to reduce the bounce-back rate.

If there are any other good message boards or listservs where I can ask this question, please let me know. Thank you!

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[Cytarabine]

Hi, I'm not sure where to go for this but thought someone in this forum could direct me. I am on rotations at a children's hospital and was tasked with finding out what other hospitals are doing for children who come in for asthma exacerbations. At our hospital based upon the severity of exacerbation, we give 2 doses of dexamethasone separated by 24-36 hours. Most of the time they are discharged with an outpatient script for the second dose, but a lot of the time they don't get the Rx filled and end up being admitted again at some point. My preceptor wanted to see if other hospitals do something different in order to reduce the bounce-back rate.

If there are any other good message boards or listservs where I can ask this question, please let me know. Thank you!

I believe there was a JAMA study that came out recently showing that patients being discharged from the hospital for an asthma exacerbation who left the hospital with meds in hand rather than with an rx had something like an 80% lower bounce back rate

Edit: here http://www.jwatch.org/fw111211/2016/02/24/asthma-medication-hand-discharge-improves-outcomes

 

[Step Up]

We also do 24-36hrs for a second dex dose. I've heard some attendings suggest 48hrs. I wish I understood the pharmacokinetics better, as I don't understand why there's such a push for 36hrs, when it's half-life is so much shorter than this. The half-life of dex is 4hrs, but its duration of action is 72hrs.

 

[Cytarabine]

We also do 24-36hrs for a second dex dose. I've heard some attendings suggest 48hrs. I wish I understood the pharmacokinetics better, as I don't understand why there's such a push for 36hrs, when it's half-life is so much shorter than this. The half-life of dex is 4hrs, but its duration of action is 72hrs.

It isn't a question of pharmacokinetics but rather pharmacodynamics. It's a steroid, and it's action is alteration of transcription of RNA, so the answer is in your last sentence. Duration of action is far longer than the half life. That said, I'm not privy to the debat regarding 24 vs 48 vs 72 hrs and the merit of each. Lexicomp says dose q24

 

[oldbearprofessor]

You might look at this, esp. Addendum 1:

https://www.dellchildrens.net/wp-content/uploads/2015/10/DCMCAsthmaGuidelines.pdf

 

[mvenus929]

Our patients sent home from the ED get a prescription. Our kids that are admitted are given the second dose before discharge, even if it's less than 24 hours after the first dose.

 

[toshimonkey]

Thanks everybody for the responses!

 

[DeadCactus]

This is a good summary of the evidence:
http://www.cfp.ca/content/57/10/1134.full

The caveat is the majority of research is based on patients being discharged from the ED and not patients being discharged from the hospital. Still, I would argue your bounce back problem likely has little to do with their medications and more to do with difficult issues like smoke exposure at home. Even within the confines of medication related issues, I would think looking at controller medication prescription and compliance would be higher yield.