Prioritizing systemic corticosteroid treatments to mitigate relapse in adults with acute asthma. A systematic review and network meta-analysis.

OBJECTIVES: While systemic corticosteroids (SCS) are widely used to prevent relapse in adults with acute asthma discharged from the emergency department, the most effective route of administration is unclear. The objective of this review was to examine the effectiveness of SCS in adults and to identify the most effective route of SCS to preventing relapse. METHODS: A search was conducted to identify randomized controlled trials comparing the effectiveness of intramuscular, oral short-course or long-course corticosteroids to prevent relapse in adults with acute asthma. Two independent reviewers judged study relevance, inclusion, and risk of bias. Pooled statistics were calculated as risk ratios (RR) and odds ratios (OR) with 95% confidence intervals (CI) and credibility intervals (CrI) using a random effects model. A Bayesian network meta-analysis was performed for indirect comparisons of SCS to placebo. Probability of best analysis was reported for comparisons between the routes of administration. RESULTS: Thirteen studies of moderate quality were included. Four studies compared SCS to placebo, in which SCS significantly reduced relapse (RR = 0.43; 95% CI: 0.25, 0.74). In the network meta-analysis, a significant reduction in relapse within 10 days of discharge was found in adults receiving intramuscular (OR 0.21; 95% CrI: 0.05, 0.73) and oral long-course (OR 0.31; 95% CrI: 0.09, 0.95) corticosteroids. Relapse rates between oral short-course corticosteroids and placebo were not statistically significantly different (OR 0.37; 95% CrI: 0.04, 3.38). Probability of best analysis favored intramuscular corticosteroids (62%) followed by oral short-course (20.3%) and oral long-course (14.1%) corticosteroids. CONCLUSIONS: The network analysis identified IM corticosteroids and oral long-course corticosteroids as the most effective strategies to prevent relapse among adults with acute asthma, compared to oral short-course corticosteroids. The lack of significant findings with oral short-course corticosteroids is likely due to the paucity of research. Further comparative studies are required to determine the safety and effectiveness of briefer oral SCS treatment options in adults. This article is protected by copyright. All rights reserved.