392 - Variation in dexamethasone prescribing practices for pediatric asthma exacerbations in acute care settings

Publication Number: 3379.392

Hannah Reilly, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Natalie J. Kane, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Sian Best, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Mark Hoffman, Children's Mercy Hospital, Kansas City, MO, United States; Kathryn E.. Kyler, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States

Background: Asthma exacerbations are a leading cause of pediatric acute care encounters, and systemic corticosteroids play a crucial role in treatment. Dexamethasone is not included in national asthma guidelines but is frequently used for asthma exacerbations in acute care settings, with little known about variation in prescribing practices.

Objective: To assess variability in dexamethasone dosing, frequency, and timing for pediatric asthma exacerbations in the emergency department (ED) and inpatient setting.

Design/Methods: This retrospective cross-sectional study used the de-identified Oracle EHR Real World Database to examine children aged 2-18 years treated for an acute asthma exacerbation in the ED and inpatient setting from 2016-2024, who received 1-2 doses of dexamethasone during an encounter. We excluded children with concurrent diagnoses of bronchiolitis, bacterial pneumonia, COVID-19, complex chronic conditions, hospital stays >5 days, or those who received systemic corticosteroids aside from dexamethasone, methylprednisolone, or prednisone/prednisolone. Dexamethasone dosing frequency, location, timing between doses, and variation in absolute and weight-based dose were analyzed.

Results: We identified 61,707 encounters; most were aged 5-9 years (41%), male (62%), and African American (45%). Nearly all encounters were in the ED (61,345) and 16,451 (27%) required hospitalization. Of the included encounters, 73% received dexamethasone in the ED only, 0.6% inpatient only, and 27% in both settings. Of the encounters seen in the ED and subsequently hospitalized, 74% received 1 dose and 26% received 2 doses of dexamethasone. For those who received two doses, 45% received the second dose within 12 hours of the initial dose, 25% within 12-24 hours, 27% within 24-36 hours, and 3% more than 36 hours after the initial dose (Fig. 1). Inter-institution variation existed in the distribution of absolute dexamethasone doses, especially for children ≥5 years (Fig. 2). Mean absolute dexamethasone dose was 9.5 mg for ages 2-4, 13.2 mg for ages 5-9, 14.6 mg for ages 10-14, and 14.5 mg for ages 15-18. Mean weight-based dose also varied by age group, ranging from 0.6 mg/kg for ages 2-4 to 0.3 mg/kg for ages 10-14 (p < 0.001, Fig. 3).

Conclusion(s): There is substantial variation in dexamethasone dosing, frequency, and timing for pediatric asthma exacerbation treatment in the ED and inpatient setting, particularly across age groups and institutions. As dexamethasone use for asthma exacerbations increases, future studies should focus on understanding the impact of this variation on clinical outcomes and potential adverse drug effects.

Figure 1. Dexamethasone Dose Timing from Time of Admission
Included encounters were those seen in the emergency department and subsequently hospitalized, and the admission time is the start of the emergency department encounter. The top panel shows the timing of dexamethasone dose for encounters with only 1 dose given. The bottom panel shows dexamethasone dose timing for encounters where 2 doses were given. Most 1st doses were given in the first hour of the encounter, and most 2nd doses were given approximately 24 hours after the start of the encounter, with some variability.

Figure 2. Absolute Dexamethasone Dose by Institution and Age Group  (years)
The blue line indicates the median dexamethasone dose for all included encounters (12mg)

Figure 3. Distribution of Dexamethasone Prescriptions by Dose (mg/kg) and Age Group (years)
Mean weight-based dexamethasone dose by age group was 0.62 mg/kg for ages 2-4 years, 0.519 mg/kg for ages 5-9 years, 0.31 mg/kg for ages 10-14 years, and 0.205 mg/kg for ages 15-18 years (p < 0.001)