Voodoo or EBM - Discharging the Asthmatic

The Gist:  When discharging adult patients home from the Emergency Department (ED) following an acute asthma exacerbation, give a short burst of corticosteroids and an albuterol metered dose inhaler (MDI) with spacer [1].  Consider prescribing a short course of inhaled corticosteroids (ICS), although this is less strongly supported by the evidence [2-5].

The "art of medicine" (i.e. voodoo) sneaks into the prescriptions given at discharge from the Emergency Department (ED) with acute asthma exacerbations.  Which oral steroid, what dose, and what duration?  What about an ICS?  Free Open Access Medical Education (FOAM) has educated me well on handling the asthmatic in extremis (ex: EMCrit, LITFL), but after generating and hearing questions about discharge medications from colleagues - I realized I should examine the rationale behind my practice.

The Case:  A 21 year old female with a history of asthma never requiring intubation presents to the ED with gradually increasing shortness of breath over the past day.  She has a history of 2 days of preceding upper respiratory symptoms. The patient states she "used up" her remaining albuterol inhaler but continued to get worse. She states she moved to the area 2 months ago and her prescription for her daily inhaler ran out and she hasn't established a local physician.  EMS found the patient working to breath and administered albuterol via nebulizer with some relief.  In the department, she receives 15 mg nebulized albuterol, 6 puffs via MDI with spacer, and 60 mg of oral prednisone. Afterward, the patient has good air movement, is comfortably chatting with her visitor, has a sparse, occasional expiratory wheeze and would like to go home. What prescriptions should I write?

Beta-agonist MDI + spacer

Prescribing a beta-agonist inhaler at discharge is standard practice.  As a medical student, I wrote about this here, emphasizing the importance of the spacer and training. Ensure patients have a spacer and can adequately use an inhaler [1].

Steroids to go. Steroids prevent relapses and hospitalizations [6,7].  Most practitioners and guidelines recommend a short burst of prednisone 40-60 mg for 5 days, although there is limited literature directly comparing dosage/duration of steroids in the dischargeable emergency department patient.

• Little literature directly comparing doses.  Despite a 55-fold variation in steroid dosing, there's no added benefit from higher doses of steroids [6,7].
• In medicine, it's becoming more apparent that more doesn't necessarily translate into better patient outcomes (ex: duration of antibiotics in uncomplicated UTI, steroids in croup) and this is likely the case with steroids in asthma.
• Two dose dexamethasone (16mg)- a prospective RCT in adults (n=257) found that this regimen was non-inferior to a five day of prednisone (60 mg) with regard to asthma symptoms and relapse [8].  Note: This is probably an unnecessarily large dose of dexamethasone (60mg prednisone = 8 mg dexamethasone), but it appears that two doses of dexamethasone may be a good alternative to patients where compliance may be an issue - perhaps more in the future? More on this from EM Lit of Note

ICS at discharge - Isn't this a primary care physician's (PCP) role?
This is the most controversial point of discharging an asthmatic - many say it's not an EP's role to prescribe these medications, yet core emergency medicine texts recommend at least considering this at discharge and it's more common practice in other countries [3,7].

In 2012, a Cochrane review covered the topic of ICS in addition to oral corticosteroids at discharge, including three RCTs with a total n=909 [4].

• Asthma relapse at 7-10 days = OR 0.72 (95% CI 0.48-1.10) and 20-24 days OR 0.68 (95% CI 0.46-1.02).There were no statistically significant differences in the number of people experiencing an asthma relapse between patients treated with ICS and those on placebo (in addition to oral steroids).  There was a trend towards benefit.
• Hospital admission was very low, at 2%, with no difference between groups so there's not sufficient power to determine a difference.
• Asthma symptoms - subjective endpoint, difficult to quantify and extrapolate, and studies have yielded conflicting results.
• One consideration with these studies is that patients were typically contacted for information at various intervals during the follow up period, serving as a reminder for compliance with various interventions (not quite real world).

Non-evidence based thoughts on ICS:  

• Access to PCP. While it's easy for us to write "follow up with your PCP within X days," this is less readily translated into reality. Patients may not have a local physician, there may be a paucity of appointment slots, or the patient may not have the time, means, or desire to follow through.  Furthermore, of those who do follow up with a PCP, many do not receive a prescription for an ICS as controller therapy according to a single center retrospective review [2].  
• Cost-effectiveness.  Researchers at MUSC performed a cost-effectiveness analysis in pediatric patients presenting with asthma and found that routine ICS prescription at discharge showed cost-savings over recommending that a patient follow up with their PCP [9].  This model is limited in that it is merely a model and based on many assumptions, but is interesting.
• The "teachable moment." ICS, in patients with asthma, prevent relapses and have thusly earned the role of "controller medication."  Experts who recommend ICS at discharge cite this as one reason 10].
• Not all patients need ICS long-term, such as those patients with mild intermittent asthma. Many providers assert that as emergency providers, it's not our role to determine the long-term management of a patient's asthma.  Yet, patients visiting the emergency department with asthma exacerbations are cited as being the patients who typically benefit from ICS therapy. The side effects of ICS are minimal and local, especially considering a short term
• Personally, I evaluate the individual patient, their access to care and compliance, their history and make a decision based on those components - knowing that a prescription for a beta-agonist MDI + spacer and a burst of systemic steroids will benefit the patient the most.  If a patient has been on an ICS in the past, I'm more likely to prescribe this at least a bridge until they see their PCP.

Note bene:  Dr. Rowe is an author on many of these papers and has the following conflict of interest: received research support and speakers fees from GlaxoSmithKline (once: $1000) and AstraZeneca (multiple: ~$3000/year) in the past 3 years; he is not a paid consultant or employee of either.

References:

1. Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma (Review). Cochrane Database Syst Rev. 2006 Apr 19;(2):CD000052.
2. Cydulka RK, Tamayo-Sarver JH, Wolf C, Herrick E, Gress S. Inadequate Follow-up Controller Medications Among Patients With Asthma Who Visit the Emergency Department. Ann. Emerg. Med. 2005;46(4):316–322.
3. Cydulka R.  "Acute Asthma in Adults."  Tintinalli's Emergency Medicine. 7th ed. p 507-510.
4. Edmonds ML, Milan SJ, Brenner BE, Camargo CA Jr, Rowe BH. Inhaled steroids for acute asthma following emergency department discharge.  Cochrane Database Syst Rev. 2012 Dec 12;12:CD002316 
5. Waxman MA, Barrett TW, Schriger DL. A tale of two steroids: answers to the September 2011 journal club questions.  Ann Emerg Med. 2012 Feb;59(2):147-55. 
6. Krishnan JA, Davis SQ, Naureckas ET, et al. An umbrella review: Corticosteroid therapy for adults with acute asthma.  Am J Med. 2009 November; 122(11): 977–991.
7.  Rowe BH, Spooner CH, Ducharme FM, et al. Corticosteroids for preventing relapse following acute exacerbations of asthma.  Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000195.  
8. Kravitz J, Dominici P, Ufberg J, Fisher J, Giraldo P. Two days of dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a randomized controlled trial.  Ann Emerg Med. 2011 Aug;58(2):200-4. 
9.  Andrews AL, Teufel RJ , Basco WT , Simpson KN. A cost-effectiveness analysis of inhaled corticosteroid delivery for children with asthma in the emergency department. J Pediatr. 2012 Nov;161(5):903-7. 
10.  Rowe RH, Bota GW, Clark S, et al. Comparison of Canadian versus American emergency department visits for acute asthma. Can Respir J. 2007 September; 14(6): 331–337.