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Inhalacijski steroidi u liječenju akutne astme nakon otpusta s odjela hitne medicine.

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Background

Patients with acute asthma treated in the emergency department (ED) are frequently treated with inhaled beta2‐agonists and systemic corticosteroids after discharge. The use of inhaled corticosteroids (ICS) following discharge may also be beneficial in improving patient outcomes after acute asthma.

Objectives

To determine the effectiveness of ICS on outcomes in the treatment of acute asthma following discharge from the ED. To quantify the effectiveness of ICS therapy on acute asthma following ED discharge, when used in addition to, or as a substitute for, systemic corticosteroids.

Search methods

Controlled clinical trials (CCTs) were identified from the Cochrane Airways Review Group register, which consists of systematic searches of EMBASE, MEDLINE and CINAHL databases supplemented by handsearching of respiratory journals and conference proceedings. In addition, primary authors and pharmaceutical companies were contacted to identify eligible studies. Bibliographies from included studies, known reviews and texts also were searched. The searches have been conducted up to September 2012

Selection criteria

We included both randomised controlled trials (RCTs) and quasi‐RCTs. Studies were included if patients were treated for acute asthma in the ED or its equivalent, and following ED discharge were treated with ICS therapy either in addition to, or as a substitute for, oral corticosteroids. Two review authors independently assessed articles for potential relevance, final inclusion and methodological quality.

Data collection and analysis

Data were extracted independently by two review authors, or confirmed by the study authors. Several authors and pharmaceutical companies provided unpublished data. The data were analysed using the Cochrane Review Manager software. Where appropriate, individual and pooled dichotomous outcomes were reported as odds ratios (OR) or relative risks (RR) with 95% confidence intervals (CIs). Where appropriate, individual and pooled continuous outcomes were reported as mean differences (MD) or standardized mean differences (SMD) with 95% CIs. The primary analysis employed a fixed effect model and heterogeneity is reported using I‐squared (I2) statistics.

Main results

Twelve trials were eligible for inclusion. Three of these trials, involving a total of 909 patients, compared ICS plus systemic corticosteroids versus oral corticosteroid therapy alone. There was no demonstrated benefit of ICS therapy when used in addition to oral corticosteroid therapy in the trials. Relapses were reduced; however, this was not statistically significant with the addition of ICS therapy (OR 0.68; 95% CI 0.46 to 1.02; 3 studies; N = 909). In addition, no statistically significant differences were demonstrated between the two groups for relapses requiring admission, quality of life, symptom scores or adverse effects.

Nine trials, involving a total of 1296 patients compared high‐dose ICS therapy alone versus oral corticosteroid therapy alone after ED discharge. There were no significant differences demonstrated between ICS therapy alone versus oral corticosteroid therapy alone for relapse rates (OR 1.00; 95% CI 0.66 to 1.52; 4 studies; N = 684), admissions to hospital, or in the secondary outcomes of beta2‐agonist use, symptoms or adverse events. However, the sample size was not adequate to exclude the possibility of either treatment being significantly inferior and people with severe asthma were excluded from these trials.

Authors' conclusions

There is insufficient evidence that ICS therapy provides additional benefit when used in combination with standard systemic corticosteroid therapy upon ED discharge for acute asthma. There is some evidence that high‐dose ICS therapy alone may be as effective as oral corticosteroid therapy when used in mild asthmatics upon ED discharge; however, the confidence intervals were too wide to be confident of equal effectiveness. Further research is needed to clarify whether ICS therapy should be employed in acute asthma treatment following ED discharge. The review does not suggest any reason to stop usual treatment with ICS following ED discharge, even if a course of oral corticosteroids are prescribed.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Inhalacijski steroidi za liječenje akutne astme nakon otpusta iz hitne službe

Akutna astma je česti uzrok posjeta hitnoj medicinskoj pomoći i većina pacijenata se nakon liječenja otpušta kući. Neki ljudi će imati ponovnu pojavu (recidiv) akutne astme u roku od dva tjedna nakon otpusta i naizgled uspješnog liječenja. Beta2 agonisti se koriste za otvaranje mišića dišnih puteva dok se kortikosteroidi koriste za smanjenje upale otečenih dišnih puteva. Kortikosteroidi se mogu davati u vidu inhalacija (inhalacjiski kortikosteroidi) ili u obliku tableta (tzv. oralni kortikosteroidi). Inhalacijski kortikosteroidi mogu smanjiti štetne učinke i izravnije doći do dišnih puteva od oralnih kortikosteroida. Ovaj Cochrane sustavni pregled utvrdio je da nema dovoljno dokaza da je udisanje kortikosteroida zajedno s uzimanjem lijekova na usta bolje nego sama oralna terapija nakon liječenja napadaja astme na hitnoj medicinskoj pomoći. Također nema dovoljno dokaza da je korištenje samo inhalacijskih kortikosteroida jednako dobro kao i oralno korištenje, iako postoje neki dokazi koji podupiru korištenje samo inhalacijskih kortikosteroida za blage napade astme nakon otpusta s hitne medicinske službe. Potrebna su daljnja istraživanja.