Adding nebulized magnesium to albuterol did not result in fewer hospitalizations among children treated in emergency departments for asthma unresponsive to first-line treatment with β2 agonists or corticosteroids, according to results from a randomized trial involving just over 800 patients.
A total of 178 of the 409 children in the study treated with the nebulized magnesium in emergency departments (EDs) (43.5%) were hospitalized versus 194 of 407 children in the placebo arm of the study (47.7%) ( difference, −4.2%; absolute risk difference 95% CI, −11% to 2.8%; P=0.26).
The researchers concluded that the study findings do not support the use of nebulized magnesium with albuterol as a second-line treatment for children with refractory acute asthma seen in EDs.
The findings were published online Nov. 24 in JAMA.
“An important challenge in the management of moderate to severe acute asthma is that the response to first-line treatments is variable,” wrote Suzanne Schuh, MD, of the Hospital for Sick Children, Toronto, and colleagues. “One well-documented reason for these treatment failures are genetic polymorphisms leading to varied response to inhaled β2 agonist and delayed improvement after corticosteroids.”
They noted that, in children refractory to this initial treatment, inhaled magnesium “would in theory seem to be an attractive second-line agent.”
“When administered intravenously to children with severe acute asthma, magnesium has been shown to decrease hospitalizations from the ED,” Schuh and colleagues wrote. “However, children are rarely discharged home after receiving IV magnesium and IV magnesium is often given with the intent to prevent intensive care admission. Clinician reluctance to use IV magnesium may be in part because of the pain associated with IV insertion and because of its well-known association with hypotension.”
The researchers noted that nebulized magnesium is both less invasive and potentially more efficacious in this setting “because this treatment mode targets the lower airway and reduces systemic exposure.”
However, previous studies in children treated for asthma attacks in EDs have been small, with the findings inconclusive.
The Magnesium Nebulization Utilization Management in Pediatric Asthma (MAGNUM PA) trial was designed to examine the efficacy of inhaled magnesium in children presenting to EDs with asthma exacerbations who remained in respiratory distress following first-line treatments.
The randomized double-blind parallel-group clinical trial, conducted in 7 tertiary-care pediatric EDs in Canada, included healthy children age 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments.
Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408). The primary outcome was hospitalization for asthma within 24 hours and secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes.
Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial. and no significant between-group differences were reported in the primary outcome.
In addition, no significant between-group differences were seen in the secondary outcomes of change from baseline to 240 minutes in:
- PRAM score (difference of changes, 0.14 points; 95% CI, −0.23 to 0.50: P=0.46).
- Respiratory rate (0.17 breaths/min; [95% CI, −1.32 to 1.67: P=0.82).
- Oxygen saturation (−0.04%; 95% CI, −0.53% to 0.46%: P=0.88).
- Systolic blood pressure (0.78 mmHg; 95% CI, −1.48 to 3.03: P=0.50).
Nausea and/or vomiting or sore throat and/or sore nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%).
A study limitation cited by the researchers included the inability to confirm physician-diagnosed asthma. In addition, only a small number of children had severe respiratory distress due to prior IV magnesium administration before randomization. The researchers noted that the study may also have been under-powered to detect small differences in favor of inhaled magnesium and the results were not generalizable to intravenous magnesium administration.
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Adding nebulized magnesium to albuterol did not result in fewer hospitalizations among children treated in emergency departments for asthma unresponsive to first-line treatment with β2 agonists or corticosteroids.
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Study findings do not support the use of nebulized magnesium with albuterol as a second-line treatment for children with refractory acute asthma seen in emergency departments.
Salynn Boyles, Contributing Writer, BreakingMED™
This research wa funded by the Canadian Institutes for Health Research, the Thrasher Research Fund, the Physicians’ Services Incorporated Foundation adn the Hospital for Sick Children.
Lead researcher Suzanne Schuh reported receiving grants from the Canadian Institutes for Health Research, the Thrasher Research Fund, Physicians Services Incorporated Foundation and Hospital for Sick Children during the conduct of the study.
Cat ID: 195
Topic ID: 89,195,254,570,730,100,192,195,63,925
