Chest
Volume 122, Issue 2, August 2002, Pages 489-497
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Clinical Investigations
ASTHMA
IV Magnesium Sulfate in the Treatment of Acute Severe Asthma: A Multicenter Randomized Controlled Trial

https://doi.org/10.1378/chest.122.2.489Get rights and content

Background

Studies of IV magnesium sulfate as a treatment for acute asthma have had mixed results, with some data suggesting a benefit for acute severe asthma, but not for mild-to-moderate asthma. In a multicenter cohort, this study tests the hypothesis that administration of magnesium sulfate improves pulmonary function in patients with acute severe asthma.

Design

Placebo-controlled, double-blind, randomized clinical trial.

Setting

Emergency departments (EDs) of eight hospitals.

Patients

Patients aged 18 to 60 years presenting with acute asthma and FEV1 ≤ 30% predicted on arrival to the ED.

Intervention

All patients received nebulized albuterol at regular intervals and IV methylprednisolone. Two grams of IV magnesium sulfate or placebo were administered 30 min after ED arrival. The primary efficacy end point was FEV1 at 240 min, and the data analysis was intent to treat.

Results

Two hundred forty-eight patients were included, and the mean FEV1 on ED arrival was 22.9% predicted. At 240 min, patients receiving magnesium had a mean FEV1 of 48.2% predicted, compared to 43.5% predicted in the placebo-treated group (mean difference, 4.7%; 95% confidence interval [CI], 0.29 to 9.3%; p = 0.045). A regression model confirmed the effect of magnesium compared to placebo was greater in patients with a lower initial FEV1 (p < 0.05). If the initial FEV1 was < 25% predicted, the final FEV1 was 45.3% predicted in the magnesium-treated group and 35.6% predicted in the placebo-treated group (mean difference, 9.7%; 95% CI, 4.0 to 15.3%; p = 0.001). If the initial FEV was ≥ 25% predicted, magnesium administration was not beneficial; the final FEV1 was 51.1% predicted in the magnesium-treated group and 53.9% predicted in the placebo-treated group (mean difference, − 2.9%, 95% CI, − 9.4 to 3.7; p = not significant). Overall, the use of magnesium sulfate did not improve hospital admission rates.

Conclusion

Administration of 2 g of IV magnesium sulfate improves pulmonary function when used as an adjunct to standard therapy in patients with very severe, acute asthma.

Section snippets

Study Patients

Patients between the ages of 18 years and 60 years presenting with acute asthma to the EDs of eight teaching hospitals were considered for enrollment. Patients were eligible if asthma was diagnosed in the past by a clinician and asthma medication was used during the previous 6 months. Patients were included if they had an FEV1 ≤ 30% predicted on presentation to the ED, were willing to remain in the ED for 4 h, and were able to give written informed consent. Exclusion criteria were a history of

Study Population

A total of 254 patient visits were randomized. Six patients were inadvertently enrolled twice, having appeared in different hospitals participating in the study, and only the first entry was included in the data analysis. The 248 remaining patients formed the intent-to-treat population. A number of patients randomized had protocol violations and were retained in the intent-to-treat data set. These included three patients whose initial FEV1 was > 30% predicted, three patients with chronic lung

Discussion

This multicenter trial demonstrates that 2 g of IV magnesium sulfate when administered as an adjunct to standard therapy improves pulmonary function in patients presenting to the ED with severe asthma. Overall, patients receiving magnesium had a final FEV1 of 48.2% predicted, compared to 43.5% predicted for patients receiving placebo. Patients with the most severe airway compromise on ED arrival had the greatest response to magnesium, and patients with an FEV1 on ED arrival closer to 30%

Appendix

The following investigators also participated in the trial: Thomas Kwiatkowski, Pamela Arsove, Helen Bloch, Boris Gabinskiy, Barbara Kirrane, Ruth Paiano, Scott Wolfson, and Adam Green, Long Island Jewish Medical Center; Mark Sprague, Jason Ganz, Robert Malin, Philip Hanline, and Bradley Spiegel, Lincoln Hospital Medical Center; Janet Carter and Marlow Price, Carolinas Medical Center; David Iacometta, Daniel Katzman, John Muratori, Dominick Fratello, Brian Blaufeux, and David Held, Jacobi

References (36)

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    Citation Excerpt :

    Some studies obtained minimal evidence supporting the use of nebulized magnesium sulfate, especially in severe cases, depending on the scoring system or pulmonary function results [58–63]. Recommendations: Magnesium sulfate may be given for moderate to severe asthma exacerbations in patients who exhibit minimal responses to bronchodilators and steroids. [64–70]. Recommendations: Insufficient data are available to support recommending the use of inhaled magnesium sulfate for severe asthma exacerbation.

View all citing articles on Scopus

This study was supported in part by a grant from the Max and Victoria Dreyfus Foundation.

Dr. Osborn is currently with the Department of Emergency Medicine, Bronx Lebanon Medical Center, Bronx, NY. Dr. Runge is currently with the National Highway Traffic Safety Administration, United States Department of Transportation, Washington, DC. Dr. Gallagher is currently with the Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY. Dr. Gaeta is currently with the Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY

A list of investigators can be found in the Appendix

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