OCS use improves short-term outcomes in acute preschool wheeze

19 Aug 2024 byAudrey Abella
OCS use improves short-term outcomes in acute preschool wheeze

In a systematic review and individual participant data (IPD) meta-analysis, the use of oral corticosteroids (OCS) improves short-term outcomes in children aged 12–71 months with acute preschool wheeze, more so among children with previous wheeze or asthma and those with moderate-to-severe acute wheeze.

“[O]ur IPD meta-analysis enabled us to show that children with acute preschool wheeze who received OCS had statistically significant improvements in [wheezing severity score (WSS)] and length of hospital stay [LOS],” said the researchers.

Compared with the placebo arm, the OCS arm had a greater change in the primary outcome of WSS at 4 hours (-1.94 vs -1.63; mean difference [MD], -0.31; p=0.011) but not 12 hours (-2.52 vs -2.43; MD, -0.02; p=0.68). [Lancet Respir Med 2024;12:444-456]

While there were more studies contributing to the 12-hour results, the effect may have been watered down by the number of children available for analyses, as most may have recovered enough to merit discharge from acute care by 12 hours. [N Engl J Med 2009;360:329-338; Lancet Respir Med 2018;6:97-106] “Although the differential at 12 hours continued to be positive for OCS vs placebo, the convergence of populations towards recovery at this timepoint limited the opportunity to observe any meaningful difference,” the researchers explained.

Furthermore, an absolute decrease in change in WSS at 4 hours was seen with OCS vs placebo in children with baseline moderate-to-severe wheeze (MD, -0.38), but not with mild wheeze (MD, -0.07). The interaction was not statistically significant (pinteraction=0.28).

The key secondary outcome of LOS was shorter with OCS vs placebo (18 vs 21.9 hours; MD, -3.18 hours; p=0.0021), with more profound effects among children with a history of wheezing or asthma (15.68 vs 20.33 hours; MD, -4.54 hours; pinteraction=0.0007) and with moderate-to-severe wheeze (20.22 vs 22.97 hours; MD, -3.38 hours; pinteraction<0.001).

Providing OCS in emergency departments (ED) was tied to a greater reduction in LOS as opposed to administering it in inpatient settings (MD, -3.28 vs -2.50 hours).

There was a higher risk of vomiting associated with OCS vs placebo use (4.5 percent vs 2.2 percent; odds ratio, 2.27; τ²<0.001), but AEs were few and generally mild, suggesting that OCS were well tolerated. “[Nonetheless,] more evidence is required on the adverse effects of OCS in acute preschool wheeze, particularly when repeat doses are used,” the researchers noted.

May refine current guideline recommendations

The seven datasets included data for 2,172 children. Of these, 1,728 (n=853 [OCS] and 875 [placebo]) were within the eligible IPD age range of 12–71 months and were included in the meta-analysis. About two-thirds of the population were boys. Prednisolone was the intervention used across all studies.

Taken together, the analysis provides reliable evidence on the early benefits of OCS in acute preschool wheeze. “Global guidelines could align to recommend the early use of OCS in preschool children with a history of previous wheeze or asthma … [This] could be clinically implementable immediately,” the researchers said.

“[Moreover,] our data support the risk-benefit approach adopted by guidelines for those presenting with moderate-to-severe wheeze,” they noted. “[Based on our] data, we advocate that those with moderate-to-severe wheeze presenting to the ED be provided with OCS, a suggestion that encompasses and refines current guideline recommendations.”

The findings also imply that OCS use may be deferred in low-risk preschool children and among those with mild acute wheeze, they said.

The investigators also underscored the importance of identifying patient characteristics that may help cut down OCS exposure among those who are least likely to respond. [Am J Respir Crit Care Med 2021;204:523-535] “[This] is a high clinical priority … Future research might help to deliver better stratification of acute preschool wheeze endotypes (eg, biomarkers such as eosinophils) that could further help to reduce OCS exposure in [these patients].”