- Researchers investigated whether prescribing one versus two doses of dexamethasone affects outcomes for children discharged from the emergency department with asthma exacerbations.
- This retrospective cohort study of 2,063 children used propensity score adjustment, a statistical method to balance patient characteristics, to mitigate confounding.
- Emergency revisit risks were 5.2% for one dose and 5.7% for two doses (risk difference 0.45%, 95% confidence interval: -1.4% to 2.3%).
- Although 61.9% of patients received a second dose, the researchers concluded that this additional treatment did not improve clinical outcomes.
- A single dose of dexamethasone is likely sufficient for treating most pediatric asthma exacerbations upon discharge from the emergency department.
The Shift Toward Simplified Steroid Regimens in Pediatric Asthma
Systemic corticosteroids are a cornerstone of treatment for pediatric asthma exacerbations, but recent years have seen a massive shift away from traditional five-day courses of oral prednisone. Emergency department use of dexamethasone surged to 95.3 percent of encounters by 2024 in a study of 491,576 visits [1]. Clinicians have increasingly adopted dexamethasone because its longer biological half-life (the time it takes for the active drug concentration to decrease by half in the body) allows for shorter regimens that reduce noncompliance events (Odds Ratio 0.12, 95% Confidence Interval 0.04 to 0.34) and lower the risk of medication-induced vomiting (Risk Ratio 0.29, p < 0.00001) [2, 3]. Multiple meta-analyses encompassing over 5,000 patients have confirmed that short-course dexamethasone is just as effective as longer courses of prednisolone for preventing relapses, showing no significant difference in hospital readmission rates (Risk Ratio 0.90, 95% Confidence Interval 0.34 to 2.35) [4, 5]. However, while the superiority of the side-effect profile of dexamethasone is well established, the optimal dosing strategy remains a point of clinical variation. To address this gap, researchers recently investigated a cohort of 2,063 children to determine whether prescribing a second dose of dexamethasone upon emergency department discharge actually provides any additional clinical benefit over a single dose [6].
Evaluating the Need for a Second Dose
To evaluate whether a multi-dose strategy is truly necessary, researchers conducted a retrospective cohort study of 2,063 children aged 2 to 20 years. These patients were discharged from either of two emergency departments after receiving treatment with dexamethasone for an acute asthma exacerbation. The investigators designed the analysis to test their hypothesis that clinical outcomes would not differ between the one-dose and two-dose groups, aiming to clarify a common area of practice variation. The primary exposure evaluated in the analysis was the prescription of a second dose of dexamethasone at discharge. The data revealed a strong preference for the multi-dose approach among treating physicians. Among the 2,063 children included in the cohort, 1,277 patients (61.9 percent) were prescribed a second dose of dexamethasone. Consequently, nearly two-thirds of children with asthma exacerbations were treated with two doses of dexamethasone rather than a single dose. This underscores a widespread prescribing habit that warrants rigorous clinical scrutiny, as eliminating unnecessary doses could streamline care and reduce the medication burden on families.
Equivalent Outcomes at 14 Days
To ensure an accurate comparison between the two treatment groups, the researchers utilized propensity score adjustment with inverse probability of treatment weighting (a statistical technique that balances patient characteristics across groups in observational data to mimic a randomized trial). Using this adjusted cohort, the investigators tracked two main clinical endpoints. The primary outcome was an emergency department revisit measured within 14 days, while the secondary outcome was a hospitalization measured within the same 14-day window. The analysis revealed no clinically meaningful difference between the regimens. In the propensity score-weighted cohort, the risk of an emergency department revisit was 5.2 percent for children who received one dose and 5.7 percent for children who received two doses. This yielded a negligible risk difference of 0.45 percent (95% confidence interval: -1.4% to 2.3%). Similarly, the risk of hospitalization was 0.85 percent in the one-dose group compared to 0.83 percent in the two-dose group, resulting in a risk difference of 0.02 percent (95% confidence interval: -0.93% to 0.89%). Ultimately, the data demonstrated that treatment with two doses of dexamethasone was not associated with improved outcomes compared to a single dose. For practicing physicians, these results suggest that one dose of dexamethasone administered in the emergency department may be sufficient to treat many children with asthma exacerbations. By eliminating the second dose, clinicians can simplify discharge instructions, reduce the medication burden on families, and avoid unnecessary steroid exposure without compromising patient safety or increasing the likelihood of relapse.
References
1. Ramgopal S, Michelson KA. Adoption of Dexamethasone for Asthma Exacerbations.. Pediatrics. 2025. doi:10.1542/peds.2024-070153
2. Dahan E, Ghazal NE, Nakanishi H, et al. Dexamethasone versus prednisone/prednisolone in the management of pediatric patients with acute asthmatic exacerbations: a systematic review and meta-analysis.. The Journal of asthma : official journal of the Association for the Care of Asthma. 2023. doi:10.1080/02770903.2022.2155189
3. Cai K, Su S, Wang Y, Zeng Y. Dexamethasone Versus Prednisone or Prednisolone for Acute Pediatric Asthma Exacerbations in the Emergency Department: A Meta-Analysis.. Pediatric emergency care. 2021. doi:10.1097/PEC.0000000000001926
4. Amagasa S, Utsumi S, Okajima K, Uematsu S. Oral systemic corticosteroids in children with acute asthma exacerbations: a systematic review and network meta-analysis. Archives of Disease in Childhood. 2025. doi:10.1136/archdischild-2024-327523
5. Wang H, Wang J, He X. The efficacy of dexamethasone compared to prednisone/prednisolone for the management of pediatric patients with acute exacerbation of asthma: a systematic review and meta-analysis.. The Journal of asthma : official journal of the Association for the Care of Asthma. 2025. doi:10.1080/02770903.2025.2526376
6. Dave S, Green-Hopkins I, Bardach NS, Grupp-Phelan J, Shapiro DJ. Dexamethasone Treatment Regimen and Clinical Outcomes in Children With Asthma Exacerbations.. Annals of emergency medicine. 2026. doi:10.1016/j.annemergmed.2025.12.010