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New Research - January 2009Corticosteroid treatment for viral-induced wheezingTwo articles appearing in the same issue of The New England Journal of Medicine evaluated the use of corticosteroids for viral-induced wheezing in young children. In one instance, oral prednisolone was administered using a five-day course of 10 mg daily for children 10 to 24 months of age, and 20 mg daily for older children. The prednisolone treated group was compared with placebo. The ages of the children were 10 months to 60 months. There were 343 in the prednisolone group and 344 in the placebo group. The primary outcome was the duration of hospitalization. Secondary outcomes were the score on the preschool respiratory assessment measure, albuterol use, and seven day symptom score. The authors concluded that "in preschool children presenting to a hospital with mild to moderate wheezing associated with a viral infection, oral prednisolone was not superior to placebo." In the other study, 129 children, ages 1 to 6 years of age, were randomly assigned to receive either fluticasone 750 mcg or placebo twice daily, beginning at the onset of an upper respiratory tract viral infection and continuing for a minimum of 10 days. The study was carried out for 6 to 12 months. The primary outcome was rescue oral corticosteroid use, and secondary outcomes included symptoms, use of beta-agonists, acute care visits, hospitalizations, and discontinuation of the study drug. In addition, change in growth and bone mineral density, basal cortisol level, and adverse events were assessed. In the fluticasone study in children with moderate to severe viral-induced wheezing, the authors found that preemptive treatment with this "high dose of fluticasone" was superior to placebo in terms of rescue oral corticosteroid administration. However, they also found that fluticasone was associated with a significant reduction in height and weight. They therefore concluded that, even though fluticasone was effective in terms of corticosteroid rescue use, the preventive approach "should not be adopted in clinical practice until long-term adverse effects are clarified." These two articles taken together therefore are somewhat conflicting in results; one finding that oral prednisolone was ineffective, and the other finding that high dose fluticasone was effective at least in one parameter, a reduction in oral corticosteroid use. If one accepts the premise of the first article, however, since oral corticosteroids were ineffective, the reduction in use of corticosteroid rescue would be irrelevant. Taken as a whole, therefore, one would interpret these data to indicate that the routine use of corticosteroids as a preventive or treatment for viral-induced childhood wheezing in a random group of children is of little use. However, there is a caveat. These children were not diagnosed as having asthma - only as wheezing with infections. If one were to analyze subgroups of children who are asthmatic, and especially those with eosinophilia, these results could have been entirely different. This issue is discussed to some extent in the article by Panickar, et al. Reference
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