IV magnesium in ED associated with subsequent hospitalization in children with asthma

IV magnesium therapy administered after initial asthma treatment in the ED was associated with subsequent hospitalization in children with refractory acute asthma, according to findings published in JAMA Network Open.

“Almost all international asthma management guidelines recommend consideration of IV magnesium as ancillary therapy in children with severe acute asthma,” Suzanne Schuh, MD, senior scientist in the division of pediatric emergency medicine at the Sick Kids Research Institute at The Hospital for Sick Children at the University of Toronto, and colleagues wrote. “However, the evidence of IV magnesium benefit is ... limited to disparate results from three small randomized clinical trials.”

Researchers conducted a post hoc secondary analysis of a double-blind randomized clinical trial that involved 816 children with acute asthma (median age, 5 years; 63.4% boys) who received treatment from September 2011 to November 2019 in seven tertiary care pediatric EDs in Canada. All children had Pediatric Respiratory Assessment Measure (PRAM) scores of at least 5 points after initial systemic corticosteroid and inhaled albuterol with ipratropium bromide therapy. Children were randomly assigned to three treatments of nebulized albuterol plus magnesium sulfate (n = 215) or 5.5% saline placebo (n = 601).

“The trial found that the administration of nebulized magnesium sulfate with albuterol to children who continued to experience moderate to severe respiratory distress after standardized initial therapy did not convey any benefit compared with placebo with albuterol,” Schuh and colleagues wrote. “Because many children in the trial also received IV magnesium after inhaled magnesium or placebo and asthma severity was measured using the validated Pediatric Respiratory Assessment Measure (PRAM) score, the trial offered a unique opportunity to assess the association between receipt of IV magnesium therapy in the ED and subsequent hospitalization.”

Among 215 children who received IV magnesium therapy, 88.4% were hospitalized compared with 29% of children who did not receive IV magnesium.

Researchers reported higher PRAM scores among children who received IV magnesium therapy after initial asthma treatment (6.7 vs. 6) and a higher likelihood of previous asthma ICU admissions (12.1% vs. 8.8%) compared with children who did not receive IV magnesium.

Factors associated with later hospitalization included IV magnesium therapy from 2011 to 2016 (OR = 22.67; 95% CI, 6.26-82.06) and IV magnesium therapy from 2017 to 2019 (OR = 4.19; 95% CI, 1.99-8.86), additional albuterol use (OR = 5.94; 95% CI, 3.52-10.01) and PRAM score increase at disposition (OR = 2.24; 95% CI, 1.89-2.65; P < .001 for all).

In addition, IV magnesium therapy was associated with 8.5 times higher odds of hospitalization among children with a PRAM score of 3 or less at disposition (OR = 8.52; 95% CI, 2.96-24.41; P < .001).

The odds of hospitalization were 10 times higher among children who received IV magnesium therapy in the ED compared with children who did not receive IV magnesium (OR = 9.76; 95% CI, 4.58-20.77; P < .001). In those who received IV magnesium, the researchers reported a 0.15-point decrease in mean PRAM score at ED disposition 60 minutes after initiation (5.39 to 5.24).

“Future research on the benefit of IV magnesium therapy in reducing hospitalization and the related safety profile may clarify the role of this therapy in refractory pediatric asthma,” the researchers wrote.