P2.176: Trends and variations in corticosteroids used for management of asthma exacerbations in the pediatric Emergency Department: A PECARN Registry Study

Background: Systemic corticosteroids are a standard part of treatment for acute asthma exacerbations (AAE). With multiple options for corticosteroid administration and no consensus recommendations, there is wide variability in corticosteroid treatment regimens across individual sites. This study aims to examine trends in corticosteroid regimens used in the management of AAE over a 12-year period and variation between study sites.

Methods: We performed a retrospective cohort study using encounters from the Pediatric Emergency Care Applied Research Network (PECARN) Registry between January 1, 2012 and November 30, 2024. We included children ages 1-17 with a diagnosis code for asthma or wheezing who received at least 2 albuterol treatments and at least one systemic corticosteroid administered or prescribed during the index visit. Children with comorbid conditions, an asthma visit within the preceding 14 days, or who did not receive a corticosteroid of interest were excluded. The primary outcome was the type of corticosteroid, categorized as enteral (PO)dexamethasone, PO prednisone/prednisolone/methylprednisolone, intramuscular (IM)/intravenous (IV) dexamethasone, or IM/IV methylprednisolone. Demographics and clinical characteristics were described by corticosteroid type using relative frequencies, means or medians as appropriate. Frequencies of each type of corticosteroid administered by site were summarized using median and interquartile ranges. Boxplots were used to describe variation in corticosteroid type used across hospitals over time. We estimated the odds ratios (OR) comparing treatment with PO dexamethasone versus PO prednisone/prednisolone/methylprednisolone for demographic and clinical characteristics using logistic regression models and adjusting for year and clinical site.

Results: There were 242,780 encounters over 17 sites eligible for analysis. During the study period, 69.1% of children received PO dexamethasone, 24.9% received PO prednisone/prednisolone/methylprednisolone, 4.9% IM/IV methylprednisolone and 1.1% IV/IM dexamethasone. There was a consistent increase in the proportion of visits receiving PO dexamethasone at sites throughout the study period (Figure 1). Table 1 summarizes demographic and clinical characteristics for encounters using PO dexamethasone versus PO prednisone/prednisolone/methylprednisolone. Use of PO dexamethasone was associated with younger age (OR 2.13, 95% Confidence Intervals (CI) 1.94 – 2.34)), Hispanic race/ethnicity (OR 1.2, CI (1.11 - 1.30), Spanish language (OR 1.23, CI (1.07 – 1.40), and public insurance or self-pay (OR 1.10, CI (1.04 – 1.15), and (1.26, CI (1.09 – 1.45) respectively). Emergency Severity Index (ESI) 1-2, children who were classified as overweight, who were assigned a moderate asthma severity or who were tachypneic on arrival were less likely to receive PO dexamethasone.

Conclusion: This study found an increasing trend in the use of PO dexamethasone in the management of AAE in PED over a 12-year period. The use of PO dexamethasone was associated with age, race/ethnicity, primary language, primary payer, and clinical characteristics. Future studies include exploring the comparative effectiveness of corticosteroids used in AAE in terms of length of stay, disposition, and revisit rates.