Oral systemic corticosteroids in children with acute asthma exacerbations: a systematic review and network meta-analysis

Correspondence to Dr Shunsuke Amagasa; [email protected]

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Short-term dexamethasone and long-term prednisolone are not significantly different in acute asthma exacerbations in children.

WHAT THIS STUDY ADDS

• A network meta-analysis approach compared the type, dosage and duration of treatment with oral corticosteroids and found no significant differences in the incidence of relapse among currently used regimens.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Short-term oral dexamethasone may be an acceptable alternative to a longer course of prednisolone.

Introduction

Children with asthma may experience exacerbations triggered by infection or other factors, often necessitating emergency medical care in a substantial subset.^1–3 Treatment begins with bronchodilators for immediate relief, followed by systemic corticosteroids, which are critical for reducing inflammation and airway hyperreactivity.⁴ Current guidelines recommend prompt corticosteroid use for moderate-to-severe episodes and mild cases unresponsive to beta-agonists.⁵ Nevertheless, symptom recurrence requiring further intervention or hospitalisation occurs in approximately 5–25% of cases.⁶

The outpatient management of paediatric asthma exacerbations frequently involves oral corticosteroid therapy, with prescribed regimens ranging from prednisolone (1–2 mg/kg daily for 3–5 days) to dexamethasone (0.3–0.6 mg/kg daily for 1–2 days).^7–11 Comparative studies, including trials and meta-analyses, have shown similar efficacy between short-term and extended prednisolone courses.^7–11 However, these meta-analyses compared prednisolone regardless of dose, duration or route of administration (oral, intramuscular), and few detailed comparative studies have addressed differences in the type, dosage and duration of treatment with oral corticosteroids.

To address this gap, we conducted a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) involving patients treated with oral corticosteroids, aiming to evaluate the efficacy differentials among oral corticosteroid regimens in terms of type, dosage and duration.

Materials and methods

Protocols and registration

This systematic review was designed based on the Preferred Reporting Items for Systematic Reviews and the Meta-analyses (PRISMA) extension statement for reporting systematic reviews incorporating NMAs.¹² The review protocol was registered in PROSPERO on 7 August 2023 (CRD 42023449189).

Studies, participants, interventions/comparators and outcomes

This review included RCTs. When the number of trials incorporating specific interventions and outcomes was limited, making NMA infeasible, they were assessed qualitatively. Conference abstracts were generally excluded from synthesis and instead evaluated qualitatively. This ensured inclusion of potentially valuable...