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 (IM) or oral (PO) 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 (PB) 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 to 0.74). In the network meta-analysis, a significant reduction in relapse within 10 days of discharge was found in adults receiving IM (OR = 0.21; 95% CrI = 0.05 to 0.73) and PO long-course (OR = 0.31; 95% CrI = 0.09 to 0.95) corticosteroids. Relapse rates between PO short-course corticosteroids and placebo were not statistically significantly different (OR = 0.37; 95% CrI = 0.04 to 3.38). PB analysis favored IM corticosteroids (62%) followed by PO short-course (20.3%) and PO long-course (14.1%) corticosteroids. CONCLUSIONS The network analysis identified IM corticosteroids and PO long-course corticosteroids as the most effective strategies to prevent relapse among adults with acute asthma, compared to PO short-course corticosteroids. The lack of significant findings with PO short-course corticosteroids is likely due to the paucity of research. Further comparative studies are required to determine the safety and effectiveness of briefer PO SCS treatment options in adults.