Piling Pelion upon Ossa: surely we already have enough non-evidence based ways of treating acute asthma?

The UK is the sick man of Europe in terms of the management of asthma in children and young people (CYP). Only one of the 28 CYP deaths assessed in the National Review of Asthma Deaths was adequately managed. Clearly, we are incapable of following established, evidence-based guidelines (https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills). Unfortunately, the response appears to be not to follow what works, but to switch to poorly evidenced strategies. One example is the use of very high, unlicenced dose ‘salbutamol weaning plans’ where children are prescribed 10 puffs (1000 μg) of salbutamol every 4 hours in reducing doses for up to 5 days (ie, up to 6000 μg salbutamol a day) after hospital or emergency department discharge. This wholly non-evidenced-based practice, which may mask the need for systemic corticosteroids, has come in by the back door despite clear-cut evidence of harm from excessive doses of β-2 agonist and evidence from adult studies detailed in the Global Initiative on Asthma (GINA) that as-needed bronchodilator shortens hospital stay for an acute attack compared with regular administration.1 More recently, some UK paediatric departments are now discharging CYP after acute treatment for asthma/wheezing attacks with a single predischarge dose of dexamethasone instead of guideline-directed advice of daily prednisolone for 3 or more days (https://www.sign.ac.uk). The rationale is that dexamethasone carries a lower risk of vomiting, and is cheaper and more convenient. However, this new practice has only a weak evidence base and is justified on heterogeneous studies of low or very low quality in meta-analyses. Keeney …