BRIDGEPORT, CONN—A low dosage of oral corticosteroids is just as effective as a higher dosage for treating acute asthma attacks, a recent study found. In addition, the low dosage causes significantly fewer adverse behavioral symptoms in children.[1]

To treat acute asthma exacerbations, the current recommendation for children is 1 to 2 mg/kg/d of oral prednisone. For adults, the recommended dosage is 40 to 60 mg/d, which corresponds to less than 1 mg/kg/d.

Daniel C. Shannon, MD, Professor of Pediatrics at Harvard Medical School in Boston, observed that for decades the recommended dose of oral corticosteroids based on body weight has been higher in children than in adults. When asked why, he said, “As far as I can discover from the literature, this happened because the dose of 2 mg/kg relieved symptoms when it was first tried. No one has since carried out a study comparing that dose to a smaller dose.”

Dr. Shannon and coauthor Sohail Kayani, MD, studied 86 children, ages 2 to 16, with acute exacerbations of mild persistent asthma. All patients were using inhaled corticosteroids and, as needed, albuterol administered via metered-dose inhalers (MDIs). Patients (43 in each group) were randomized to receive a five-day course of prednisone or prednisolone at dosages of either 1 mg/kg/d (group 1) or 2 mg/kg/d (group 2).

At the end of the treatment period, parents answered a telephone questionnaire that mentioned the possibility of adverse behavioral effects as well as the most commonly reported side effects of oral corticosteroids. Parents were also asked if asthma symptoms had resolved by the end of treatment.

HIGHER DOSES, MORE SYMPTOMS

All of the patients in both groups completed the course of oral corticosteroids and used albuterol MDIs as prescribed. While the two doses of oral corticosteroids did not differ in terms of efficacy, behavioral side effects—especially anxiety and aggressive behavior—were more common with the higher dosage.

All patients in group 1 and all but one patient in group 2 had complete resolution of asthma symptoms. Anxiety occurred in two children in group 1 and nine in group 2; aggressive behavior developed in zero and nine children in groups 1 and 2, respectively. At one-month follow-up, one child in group 2 had persistent anxiety.

“It has been known for years that an occasional child patient—particularly an adolescent—would have an adverse behavioral reaction,” said Dr. Shannon. “But in most children, an adverse behavioral response to asthma therapy has generally been attributed to the use of ß-agonist therapy.”

The behavioral symptoms in this study were similar to those reported in adults receiving corticosteroids at dosages as low as 40 mg/d.

Drs. Shannon and Kayani noted that although their findings were limited to children with mild persistent asthma, it is unlikely that more severe asthma would respond differently. They concluded that because the aim of any treatment is to get the best results with the fewest side effects, it may be prudent and safer to use the lower dose.

—Gale Jurasek