Steroid Storms: Controversies and Considerations in PEM

Transcription

1 Steroid Storms: Controversies and Considerations in PEM Kimball Prentiss, MD, FAAP Division of Pediatric Emergency Medicine September 19, 2018 CCEM Conference, Northampton

2 Objectives Develop an understanding of the evidence for the use for or against steroids in common, reasonably common, and/or high-risk clinical conditions within pediatric emergency medicine

3 OUTLINE asthma bronchiolitis croup anaphylaxis pharyngitis meningitis hsp cautionary tales crystallize

4 ABCs asthma bronchiolitis croup

5 ABCs asthma? bronchiolitis croup

6 ABCs asthma YES bronchiolitis croup

7 ABCs asthma YES dex vs methylprednisolone? 1 dose vs 3 vs 5? inhaled corticosteroids (ICS)?

8 ASTHMA: Where does the evidence lead us? National Heart, Lung, Blood Institute of NIH guidelines last updated in 2007 prednisone PO 1-2 mg/kg/day (max 60 mg/day) What about Dexamethasone?

9 DEX: Where does the evidence lead us?

10 DEX: Where does the evidence lead us? comparable efficacy between 1-2 dose dex and 3-5 doses oral pred no difference in return visits or readmissions less vomiting improved compliance Keeney G, Gray M, Morrison A et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2014;133(3):

11 3 vs 5: Where does the evidence lead us? Chang AB, Clar R, Sloots TP, Stone DG et al. A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalized: a randomized controlled trial. Med J Aust. 2008;189(6):

12 ICS: Where does the evidence lead us? Sampayo EM, Mazer M, Camp EA and Zorc, JJ. Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial. Ann Emerg Med. 2017;70(3): Edmonds Edmonds ML, Milan SJ, Camarga CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev Dec;12:CD

13 ABCs asthma bronchiolitis? croup

14 ABCs asthma bronchiolitis NO croup

15 BRONCHIOLITIS: Where does the evidence lead us?

16 BRONCHIOLITIS: Where does the evidence lead us?

17 BRONCHIOLITIS: Where does the evidence lead us?

18

19 asthma bronchiolitis croup? ABCs

20 ABCs asthma bronchiolitis croup? mild? moderate? severe?

21 STEROID?? YES YES YES

22 MILD CROUP: Where does the evidence lead us?

23 ABCs HOW MUCH? low-dose(0.15 mg/kg) vs high (0.6 mg/kg) HOW? PO vs NEB vs IM WHICH? dex vs pred

24 CROUP: Low-dose vs high-dose dex low-dose as efficacious as high-dose symptoms scores and return visits fewer side effects Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emerg Med Australas. 2007;19(1):51-58

25 CROUP: route equivalence between routes oral preferred Russell K, Weibe N, Saenz A et al. Glucocorticoids for croup. Cochrane Database Systemic Review. 2004;1: CD (Systematic Review; 31 studies, 3767 patients) Geelhold GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebocontrolled trial. Pediatr Pulmonol. 1995;20(6): Klassen TP, Craig WR, Moher S, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA. 1998;279(20):

26 CROUP: dex vs pred Fifoot AA, Ting JY RDBPCT 2007 single dose oral prednisolone (1 mg/kg) as efficacious as single dose low-dose dex (0.15 mg/kg) Sparrow A, Geelhoed G RDB controlled equivalence trial 2006 single pred less effective than single dose dex in reducing unscheduled repeat visits mild-moderate croup Garrbutt et al 2013 pred 2 mg/kg/d x 3 days vs dex 0.6 mg/kg (+2 placebo) no differences (unscheduled visit, duration, disturbed sleep)

27 CASE 1 4 year old F BIBEMS with drooling, urticaria, wheeze, vomiting and hypotension. Epi Would you give steroids? I would

28 CASE 2 3 yo F BIBEMS with urticaria and drooling Steroids?

29 ANAPHYLAXIS: where does the evidence lead us? Lewis et al no statistical difference in the corticosteroid treated groups re uniphasic vs biphasic reactions Lee et al no evidence to support corticosteroid use to decrease biphasic NO reactions EVIDENCE 2012 Cochrane review lack of adequate randomized controlled trials ( ) unable to make any recommendations for the use of glucocorticoids in anaphylaxis Gruneau et al no difference in bounce back within 7 days or biphasic

30 CASE 3 13 yo GAS+ on day 1 Amoxicillin, NSAID RTC ED visit for inability to take PO due to pain No drooling No trismus Kissing tonsils, exudative, no asymmetry Steroids?

31 PHARYNGITIS: where does the evidence lead us? REDUCE DURATION OF PAIN: insufficient evidence to endorse routine use

32 CASE 4 6 month immunized infant with fever bulging fontanelle, vomiting, paradoxical irritability wbc 25, crp 7 LP results pending steroids?

33 MENINGITIS: where does the evidence lead us? AAP and IDSA IF BACTERIAL and > 6 weeks dex 0.15 mg/kg IV every 6 hours best before antibiotics at least concurrent

34 CASE 5 4 yo M dx with HSP by pcp 2 days ago unable to ambulate intermittent severe abdominal pain tea colored urine steroids? for which indication?

35 HSP: where does the evidence lead us? Weiss et al articles Cochrane Review studies Conflicting evidence KDIGO YES, if nephritis NO for prevention

36 CAUTIONARY TALES? cerebral thrombosis gi bleeding growth restriction bacterial tracheitis behavioral changes NO EVIDENCE Thabet A, Greenfield T, Cantor R. Corticosteroid Use In Management of Pediatric Emergency Conditions. Pediatric Emergency Medicine Practice: An evidence-based approach to pediatric emergency medicine. 2018;15(3):1-15.

37 CAUTIONARY TALES?

38 SUMMARY asthma bronchiolitis croup anaphylaxis pharyngitis meningitis hsp

39 SUMMARY YES asthma croup CONSIDER anaphylaxis pharyngitis meningitis hsp NO bronchiolitis

40 References

41 References Thabet A, Greenfield T, Cantor R. Corticosteroid Use In Management of Pediatric Emergency Conditions. Pediatric Emergency Medicine Practice: An evidence-based approach to pediatric emergency medicine. 2018;15(3):1-15. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134:e1474-e1502. A randomized trial of a single dose of oral dexamethasone for mild croup. N Eng J Med (13): US Department of Health and Human Services, National Hear, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert panel report 3:guidelines for the diagnosis and management of asthma 2007, available at: Accessed February 15, 2018 (Guidelines) Sampayo EM, Mazer M, Camp EA and Zorc, JJ. Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial. Ann Emerg Med. 2017;70(3): Keeney G, Gray M, Morrison A et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Metaanalysis. Pediatrics. 2014;133(3): Edmonds ML< Milan SJ, Camarga CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev Dec;12:CD Chang AB, Clar R, Sloots TP, Stone DG et al. A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalized: a randomized controlled trial. Med J Aust. 2008;189(6): Russell K, Weibe N, Saenz A et al. Glucocorticoids for croup. Cochrane Database Systemic Review. 2004;1: CD (Systematic Review; 31 studies, 3767 patients) Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emerg Med Australas. 2007;19(1):51-58.

42 References Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emerg Med Australas. 2007;19(1): Alesehr A, ALmegamas, T, Hammdi, A. Efficacy of a small dose of oral dexamethasone in croup. Biomedical Research. 2005;16(1): Geelhold GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol. 1995;20(6): Klassen TP, Craig WR, Moher S, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA. 1998;279(20): Geelhold GC. Budesoide offers no advantage when added to oral dexamethasone in the treatment of croup. Pediatric Emerg Care. 2005;21(6): Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015(9):CD Bernardo WM, Aires FT, Sa FP. Effectiveness of the association of dexamethasone with antibiotic therapy in pediatric patients with bacterial meningitis. Rev Assoc Med Bras. 2012;58(3): Weiss PF, Feinstein JA, Luan X, et al. Effects of corticosteroid on Henoch-Schonlein purpura: a systematic review. Pediatrics. 2007;120(5): Chartapisak W,Opastirakul S, Hodson EM et al. Interventions for preventing and treating kidney disease in Henoch-Schonlein Purpura. Cochrane Database Syst Rev. 2009(3):CD