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Evidence Table for IV Magnesium Treatment for Asthma Intravenous Magnesium for Acute Asthma: Failure to Decrease Emergency Treatment Duration or Need for Hospitalization (217 prior to exclusion) 120 participants (58 in magnesium group and 62 in control group) Description: Patients presenting with acute exacerbation of asthma to ED. Exclusion Criteria: Atherosclerotic heart disease, angina, chest pain, uncontrolled hypertension,
congestive heart failure, heart block, metastic cancer, renal disease, temperature above 38.3 degrees celsius, systolic BP < 120mm Hg, pregnancy, radiographic evidence of
pulmonary disease, requiring mechanical ventilation in ED, or hospitalization. Age = 40.0 IV mag, 39.8 control, Gender = 79% female IV mag, 74% female control, Ethnicity =
Population
59% white IV mag, 64% white control, 33% hispanic IV mag, 21% hispanic control, 5% black IV mag, 10% black control. Asthma Severity
Standard of Care: Oxygen, 125 mg IV methylprednisolone, albuterol. Treatment: Patients on odd days given 2g magnesium sulfate diluted in 50mL D5W IV over 20 minutes -
given immediately after methyl-prednisolone administration and within 45 minutes of treatment initiation. Alternative Therapy: Other therapy (E.g. theophylline, injectable B-
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1) Physicians were not blinded to patient randomization but patients and respiratory therapists were unaware that a study was 22% in Magnesium group (95%CI 13-32), 17% Prospective Randomized being performed (-1) No Deductions No Deductions 2.4 +/- 1.5 IV mag, 2.1 +/- 0.7 control, p = 224 +/-75 IV mag (95%CI 208-240), 228 +/- 122 +/- 75 IV mag (95%CI 106-138), 133 +/- 103 +/- 91 IV mag (95%CI 83-123), 123 +/- Evidence Table for IV Magnesium Treatment for Asthma Intravenous Magnesium Sulfate for the Treatment of Acute Asthma in the Emergency Department (40 - prior to exclusion) 38 entered in study (19 Population Description: Patient presenting to ED with acute asthma exacerbation. Exclusion criteria: Rectal temperature > 38 degrees celsius, SBP < 120mmHg, history of
kidney disease, purulent sputum, infiltrate on chest roentgenogram, pregnancy, average PEFR over 200L/min. Age = 39.9+/-12.4 IV mag, 36.2+/-11.5 control, Gender =
Population
unclear, Ethnicity = 89% black, 0% white for both IV mag and control.
Asthma Severity
Standard of Care: Patients (PEFR < 200 L/min) given nebulized metaproterenol sulfate (0.3 mL in 3.0mL of saline) or albuterol sulfate (0.5mL in 2.5mL of saline) based on
physician decision as well as 125 mg of methylprednisolone intravenously. Theophylline (0.5mg/kg/hr maintenance infusion). Post 1st nebulization, 45-60min later 2nd
nebulization given. 15min later obtained PEFR. Patients who did not double their PEFR = poor responders and were randomized. Treatment: Infusion 1.2g of magnesium
Interventions
sulfate in 50mL of saline over 20min. Control: Saline placebo in 50mL of saline over 20min.
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Figure 1 - Significant results however difficult to Significant difference (0.043), main effects with blind, placebo-controlled time (p<0.001), group by interaction (p<0.05) trial 15/19 of placebo group required admission whereas only 7/19 for IV mag. (p<0.01) Evidence Table for IV Magnesium Treatment for Asthma Intravenous Magnesium Sulfate as an Adjunct in the Treatment of Acute Asthma (149 - prior to exclusion) 135 in final analysis (67 in mg, 68 in placebo) Population Description: Patients presenting to ED with acute asthma and FEV-1 < 75% predicted before/after albuterol. Exclusion Criteria: History of congestive heart
failure, diabetes mellitus, angina, chronic renal insufficiency, temperature >38 degrees celsius, pneumonia, pregnant, requiring intubation, unable to perform spirometry, unable
to give informed consent, FEV1 was >/= to 75% predicted, on presentation/post-albuterol. Age = 36+/-12.7 Mg, 38.6+/-13.2 placebo, Gender(%female) = 73% Mg, 71%
Population
placebo, Ethnicity = N/A
Asthma Severity
Severe = < 25% predicted FEV1, Moderate = 25-75% predicted FEV1 Standard of Care: Nebulised albuterol (2.5mg in 2.5ml) . Given 125mg methylprednisolone if % predicted FEV1 <40% or those who had received oral prednisone within 6
Interventions
months of study. Treatment: At 30min, randomized to 2g IV magnesium sulfate or 50ml Saline IV (placebo).
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35.3% in the placebo group and 25.4% in the 78.6% in the placebo group and 33.3% in the Fig 1 - deemed to be significant impact in favor % predicted FEV1 at 120min - severe group 22.4% in the placebo group and 22.2% in the Fig 1 - deemed to be non-significant in favor of % predicted FEV1 at 120min - moderate group Evidence Table for IV Magnesium Treatment for Asthma Intravenous magnesium therapy for moderate to severe pediatric asthma: Results of a randomized, placebo-controlled trial Population Description: Patients (6-18 yo) with acute asthma presenting to ER with PEFR < 60% predicted following 3 B-agonist nebuliser treatments. Exclusion Critieria:
PEFR > 60% predicted post 3 b-agonist nebulizer treatments. T > 38.5 C, systolic BP < 25th percentile for age, history of cardiac, renal or pulmonary disease, pregnancy, or
Population
recent theophylline. Age = 10.8+/-3.6 for IVmag, 11.9+/-3.6 placebo, Gender(% male) = 46.6% IVmag, 43.8% placebo, Ethnicity =N/A
Asthma Severity
Standard of care: Patients given oxygen, nebulized beta-agonists (0.15mg/kg in 3ml of saline). About 75% received intravenous methylprednisolone. Treatment:IV
Interventions
magnesium sulfate, 25mg/kg (maximum 2g) over 20min, Control: equal volume of saline solution over 20 min. Inconsistent Indirectness of
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Randomized, double-blind, placebo-controlled, % of improvement in PEFR 80min post Ivmag No Deductions No Deductions No Deductions % of improvement in PEFR 110min post Ivmag PEFR <60% predicted at end of observation period Fig. 2 -Values difficult to deduce, in favor of Fig. 2 - Values difficult to deduce, in favor of Values difficult to deduce, in favor of Ivmag; p No significant difference - values not given Evidence Table for IV Magnesium Treatment for Asthma Magnesium Sulfate as an adjunct to standard therapy in acute severe asthma (abstract) 249 patients were randomized (127 placebo and 122 MgS04) Population Description: Acute asthma patients (18-60 years) presenting with % predicted FEV-1 </= 30 to ER. . Median Age = 34 years, Gender = 52% female. Ethnicity
Population
Asthma Severity
Standard of care: Oxygen, nebulized inhaled albuterol (2.5mg) at 0, 30, 60, 120, and 180 minutes. IV 125mg methylprednisolone administered at t=0. Treatment: 2 gm of IV
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magnesium sulfate at 30min. Control: 50cc of saline at 30min.
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Baseline - 23% placebo, 23.5% Ivmag; 240min - Placebo-controlled, double-39.5% predicted in placebo group, 46% No Deductions No Deductions No Deductions Evidence Table for IV Magnesium Treatment for Asthma Magnesium Bolus or Infusion Fails to Improve Expiratory Flow in Acute Asthma Exacerbations 48 asthmatic patients - 21 placebo, 15 bolus, 12 infusion Population Description: Patients (18-60 yo) with initial PEFR < 200L/min - failed to double their initial PEFR post 2 albuterol treatments. Exclusion Criteria: PEFR > 200
L/min pre-treatment, first episode of wheezing, history of chronic bronchitis/emphysema, oral temperature > 38.2C, history of renal failure or congestive heart failure, or
Population
requiring tracheal intubation. Age = 36.2 placebo, 42.9 bolus, 41.4 infusion, Gender (% male) = 52.3 placebo, 53.3 bolus, 16.7 infusion, Ethinicity = N/A
Asthma Severity
Standard of care: Nebulised albuterol (2.5 IV every 30 minutes), standardized aminophylline (serum levels at 15mg/l) and IV methylprednisolone (125 mg ). Treatment: 2
methods of administration: 1) loading dose of IVmag, 2g over 20 minutes followed by 2g/h over 4 hours (infusion) or 2) MGS04, 2g over 20 minutes folllowed by placebo
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No significant differences - values difficult to No significant differences - values difficult to Evidence Table for IV Magnesium Treatment for Asthma Intravenous Magnesium Sulfate In Acute Severe Asthma Not Responding to Conventional Therapy Population Description: Children (1-12 yo), presenting to ED with severe asthma & poor response to initial therapy. Exclusion Criteria: T > 38.0C (axillary), BP < 50% for
Population
age and gender. Mean age = 36.7 SD 3.62 IVmag, 6.75 SD 3.5 placebo, Gender (%Male) = 19/24 IVmag, 17/23 placebo.
Asthma Severity
Severity: mild, moderate, severe based on a rating sytem from the National Heart, Lung and Blood Institute (USA) Standard of Care: Nebulised salbutamol (0.15mg/kg/dose) every 20 minutes for 1h. IV/po corticosteroids, aminophylline infusion, oxygen and +/- subcutaneous epinephrine.
Interventions
Treatment: 0.2ml of 50% MgS04 in 30ml (100mg/kg) in 5% dextrose over 35 minutes Control: normal saline in 30ml of 0.25 saline in 5% dextrose over 35 minutes.
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Randomized, double-blind, placebo-controlled Median Clinical Asthma Scores 1h postIVmag No Deductions No Deductions No Deductions Median Clinical Asthma Scores 2h postIVmag Median Clinical Asthma Scores 3h postIVmag Median Clinical Asthma Scores 11h postIVmag Values difficult to estimate; significantly higher Values difficult to estimate; significantly higher Values difficult to estimate; significantly higher Values difficult to estimate; significantly higher Values difficult to estimate; significantly higher Values difficult to estimate; significantly higher Values difficult to estimate; significantly higher Values difficult to estimate; significantly higher Values difficult to estimate; significantly higher Values difficult to estimate; significantly higher 13.6+/-6.8h Ivmag, 18.9+/-7.7h; p<0.05 Serum Magnesium Concentration pre to post- 0.61+/-0.15mmol/L to 1.71+/-0.21mmol/L p Serum Magnesium Concentration pre to post-infusion in Placebo patients 12.5% epigastric warmth, 16.6% pain, 12.5% tingling and numbness at site of infusion Evidence Table for IV Magnesium Treatment for Asthma Intravenous magnesium sulfate in acute severe asthma 34 patients before exclusion. 33 remains (17 Mg, 16 placebo) Population Description: Patients (15-65 yo) with acute severe asthma attack (severity scores > 4). Exclusion Criteria: History of heart disease, hypertension, diabetes
mellitus, chronic renal disease, infection, pregnancy (suspected or confirmed) and FISCHL index of 4+. Mean Age = 42.88+-2.99 SD Mg group, 35+-3.03 SD placebo group,
Population
Gender (%Male) = 11.76% Mg, 12.50% placebo, Ethnicity = N/A
Asthma Severity
Standard Treatment: 5mg IV dexamethasone, 2.5mg nebulized salbutamol at 0, 20, 40, and 60min, and oxygen via mask (if necessary). Treatment: Randomly allocated
Interventions
patients received either 2g IV MgSO4 or placebo, sterile water as an adjunctive medication. Medication diluted in 50ml of 0.9% saline.
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17.65% MgS04; 25% placebo; RR 071 (95%CI 0.19-2.67). Risk Ratio 0.71 (95%CI 0.19-2.67) Randomized double-blind No Deductions No Deductions No Deductions Treatment - SS 0.41, DoF 1, MS 0.41, Adjusted F-ratio 0.33, p-0.571; Error - SS 39.04, DoF 31, Time - SS 17.92, DoF 3*0.763, MS 5.97, Adjusted F-ratio 0.000; Treatment*time - SS 0.4, DoF 3*0.763, MS 0.15, Adjusted F-ratio 1.04, p-value 0.366; Error - SS 13.29, DoF Evidence Table for IV Magnesium Treatment for Asthma Higher-Dose Intravenous Magnesium Therapy for Children with Moderate to Severe Acute Asthma 38 enrolled - 30 remained post-exclusion (16 Ivmag, 14 placebo) Population Description: Patients (6 to 17.9 yo) with acute exacerbation needing 3 nebulized bronchodilating treatments (albuterol or ipratropium bromide or a combination).
Exclusion Criteria: Body temperature > 38.5 degrees C, theophylline use (<1 week), history of cardiac, renal or pulmonary disease (exc. asthma). Mean Age = 10.9+-0.9
Population
IVmag, 12.0+-1.0 placebo; Gender (Male %) = 68% IVmag, 50% placebo, Ethnicity= N/A
Asthma Severity
Standard of Care: 3 nebulized bronchodilating treatments (albuterol or ipratropium bromide or a combination). After enrollment, intravenous methylprednisolone (2mg/kg -
max 100g) was given (patients who had not gotten corticosteroids). Treatment: Patients randomized: 1) magnesium sulfate 40mg/kg - max 2g in 100ml normal saline or 2)
Interventions
equivalent volume of saline (placebo).
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Fig 1 - contact author for values - p<0.001 No Deductions No Deductions No Deductions Fig 1 - contact author for values - p<0.001 Fig 1 - contact author for values - p<0.001 Fig 2 - contact author for values - p<0.001 FEV1 % predicted - 30minutes post-infusion Fig 2 - contact author for values - p<0.001 Fig 2 - contact author for values - p<0.001 Fig 3 - contact author for values - p<0.001 FVC % predicted - 30minutes post-infusion Fig 3 - contact author for values - p<0.001 Fig 3 - contact author for values - p<0.001 % improvement from Baseline - PEFR - 20min Fig 4 - contact author for values - p<0.001 % improvement from Baseline - PEFR - 110min Fig 4 - contact author for values - p<0.001 Evidence Table for IV Magnesium Treatment for Asthma A Randomized Trial of Magnesium in the Emergency Department Treatment of Children With Asthma 62 eligible (8 refused) 54 children (24 Ivmag, 30 placebo) Population Description: Children (1-18 yo) with moderate to severe asthma exacerbation presenting to ED. Exclusion Criteria: Less severe (PI score </= 7) or more severe
(PI score >/= 14) ill children. Corticosteroid use (last 72h), concurrent bronchiolitis, lobar pneumonia, croup, suspected foreign body aspiration, history of cystic fibrosis,
bronchopulmonary dysplasia, congenital heart disease, liver disease, renal disease, sickle cell anemia, or pregnancy. Mean age = in months (SD): 81+-44 IVmag, 58+-39
Population
placebo, Gender (%Male) = 58% IVmag, 47% placebo, Ethnicity = 58% black IVmag, 63% black placebo.
Asthma Severity
Standard of Care: Nebulized albuterol treatment (0.15mg/kg) and methylprednisolone (1mg/kg). Treatment: Post standard-of-care randomly assigned to receive 75mg/kg of
Interventions
magnesium sulfate (max 2.5 g) or placebo. Post-randomization, all patients treated with nebulized albuterol (structured protocol).
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Mean PI scores for all 7 assessment times (0, 120min) showed significant improvement - in Mean change in PI from baseline to 120min 2.83 (SD=+-2.44) Ivmag; 2.66 (SD=+-2.65). " " Mean differences in PI scores- Ivmag vs. placebo T=0min Mean differences in PI scores- Ivmag vs. placebo T=20min Mean differences in PI scores- Ivmag vs. placebo T=30min Mean differences in PI scores- Ivmag vs. placebo T=40min Mean differences in PI scores- Ivmag vs. placebo T=60min Mean differences in PI scores- Ivmag vs. placebo T=80min Mean differences in PI scores- Ivmag vs. placebo T=120min Physician determination of need of hospitalization after 150min Evidence Table for IV Magnesium Treatment for Asthma Intravenous Magnesium Sulfate As an Adjunct in the treatment of severe asthmatic patients non-responding to conventional therapy The Internet Journal of Asthma, Allergy and Immunology Population Description: Asthma patients (12-85 yo) with acute exacerbation (PEFR <200L/min with bronchodilators, corticosteroids and assisted ventilation). Age: 12-85
Population
range Ivmag, 15-80 range placebo. Gender (%male): 54.2% Ivmag, 51.5% placebo, Ethnicity: N/A
Asthma Severity
Standard of Care: Oxygen, nebulized salbutamol, IV aminophyllin and corticosteroids. Treatment: Randomized to receive MgS04 (25mg/kg) or saline (100ml normal saline)
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placebo given as infusion (over 30-45min).
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placebo; 30min - 62.81+-6.7 Ivmag, 46.52+- No Deductions No Deductions No Deductions Baseline - 31.46+-5.6 Ivmag, 30.00+-5.9 placebo; 3h - 82.60+-5.8 Ivmag, 47.8+-8 Baseline - 34.38 Ivmag, 35.1 placebo; 30min 27.21 Ivmag, 33.20 placebo; 3h 24.42 Ivmag, Baseline - 29.2% Ivmag, 30.3% placebo; 3h - Baseline - 35.4% Ivmag, 22.7% placebo; 3h - Baseline - 100% Ivmag, 40.9% placebo; 3h - Evidence Table for IV Magnesium Treatment for Asthma Intravenous magnesium is ineffective in adult asthma, a randomized trial 55 met inclusion criteria - 42 patients: 18 Ivmag, 24 placebo Population Description: adult asthma patients (18-55 yo) presenting to ED (PEF of <100 L/min or <25% of predicted flow). Exclusion Criteria: SSx pneumonia, congestive
heart failure, renal insufficiency, previous myocardial infarction, hypertension on therapy and hypertension/hypotension (SBP >180 or <110mmHg), pregnancy, or patients with
Population
high likelihood of endotracheal intubation. Age = 32+-13 IVmag, 38+-15 placebo, Gender (%Male) = 50% IVmag, 25% placebo, Ethnicity = N/A
Asthma Severity
Standard of Care: 2.5mg albuterol sulphate via nebulizer, 125mg methylprednisolone IV, oxygen as needed. Treatment: Patients given either 2.0 grams of MgS04 or placebo.
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All received inhaled bronchodilators and IV steroids Inconsistent Indirectness of
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(bivariate)=0.038; p(multivariable) 0.132 No Deductions No Deductions No Deductions 211+-104L/min Ivmag, 252+-108L/min Placebo; p(bivariate) = 0.28, p(multivariable) 2.2 Ivmag, 1.6 Placebo; p(bivariate) = 0.682, 1.3 Ivmag, 0.9 Placebo; p(bivariate) =0.807, Evidence Table for IV Magnesium Treatment for Asthma IV Magnesium Sulfate in the Treatment of Acute Severe Asthma: A Multicenter Randomized Control Trial 254 were randomized - (6 were enrolled 2times) 248 Population Description: Patients (18 to 60 yo) presenting to ED with acute asthma (FEV1 </= 30% predicted). Exclusion Criteria: History of COPD or other chronic lung
disease, diabetes mellitus, renal insufficiency, or hypertension on medication, temperature was >38.9C, or suspected pneumonia, pregnancy, requiring intubation or unable to
perform spirometry, congestive heart failure, coronary artery disease, requiring intubation. Age = 36.5(11.4) placebo, 36.4(11.1) IVmag, Gender (%female) = 49% placebo,
55 IVmag, Ethnicity = 38% black placebo, 39% black IVmag; 43% hispanic placebo, 43% hispanic IVmag; 11% white placebo, 14% white IVmag, 8% other placebo, 4% other
Population
Asthma Severity
Interventions
Standard of Care: Nebulized albuterol at regular intervals and IV methylprednisolone. Treatment: 2g of IV magnesium sulfate or placebo 30min after ED arrival.
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Baseline - 104 placebo, 100 Ivmag; 240min - Pulse rate (beats/min) at baseline to 240min No Deductions No Deductions No Deductions Mean difference (95%CI) at 240 min - pulse rate (beats/min) Baseline - 0.75 placebo, .76 Ivmag; 240min - 1.42 (0.66) placebo; 1.60 (0.69) mag; p<0.05 " " Mean difference (95%CI) at 240 min - FEV1 L Baseline - 22.7 (5.7) placebo; 23.1 (4.9) mag; 240min - 43.5 (18.7) placebo; 48.2 (18.1) Mean difference (95%CI) at 240 min - FEV1 % predicted At baseline - 144 (73) placebo; 141 (74) mag; 240min - 236 (123) placebo; 272 (144) mag; Mean difference (95%CI) at 240 min - PEFR L/min Baseline - 32.0 (14.0) placebo; 32.2 (18.0) mag; 240min - 53.1 (20.9) placebo; 62.7 Mean difference (95%CI) at 240 min - PEFR 39/122 Ivmag, 41/126 Placebo, 32% in both Evidence Table for IV Magnesium Treatment for Asthma Intravenous magnesium sulphate provides no additive benefit to standard management in acute asthma 150 before exclusion (129 in final analysis) 62 Ivmag, 67 placebo Population Description: Patients (16+ yo) presenting with acute asthma attack (PEF <75%), and past asthma diagnosis wrt BTS guidelines. Exclusion Criteria: COPD ( or
other chronic lung disease), pneumonia, congestive heart failure, coronary artery disease, renal insufficiency, hypertension (w/ medication), inability to perform spirometry,
Population
pregnancy. Age = 36(18-73) mg, 38.8(17-73) placebo, Gender (% male) = 39% mg, 45% placebo, Ethnicity = N/A
Asthma Severity
Standard of Care: 35% oxygen, 5mg nebulised salbutamol, 500mcg nebulized ipratropium and 200mg IV hydrocortisone. Treatment: Patients were randomized to receive
Interventions
1.2g MgSO4 in 50ml saline or placebo consisting of 50ml normal saline over 15min.
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Life Threatening Group (12 Mg; 17 placebo)
Mean difference in % predicted PEF at T=60 Severe Group (30mg; 31 placebo)
Moderate Group (20 Ivmag; 19 placebo)
Adverse Events
Mg - trend to decrease SBP at t=60, (t=0, Evidence Table for IV Magnesium Treatment for Asthma Intravenous magnesium sulphate in the management of moderate to severe acute asthmatic children nonresponding to conventional therapy Population Description: Patients with acute asthma exacerbation (PEFR <60% predicted) post 3 b2-agonist nebulizer treatments (0.15mg/kg/dose, max 5mg/dose of
salbutamol solution in 3ml normal saline). Exclusion Criteria: Fever, systolic blood pressure (less than 25th percentile of age), theophylline (recent use), history of cardiac,
Population
renal or pulmonary diseases. Mean age: 10.8+-2.8 years, Gender (% male) = 55%, Ethnicity: NA
Asthma Severity
Standard of Care: Intravenous infusion of methylprednisolone (2mg/kg; max 100mg) with first nebulizer. Treatment: 40mg/kg doses (2g max) or equivalent volume of
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Mean % of improvement from baseline in PEFR 43.0+-6.3% Ivmag; 14.6+-3.7% placebo; No Deductions No Deductions No Deductions Mean % of improvement from baseline in PEFR 58.4+-2.9% Ivmag; 21.8+-4.5% placebo; at end of observation (post-IV mag infusion) Mean Clinical Asthma Score -30min from baseline - Placebo Baseline - 5.5+-0.5; 30min - 5.7+-0.5; p>0.05 " " % individuals at end of observation with PEFR <60% predicted Evidence Table for IV Magnesium Treatment for Asthma A meta-analysis on intravenous magnesium sulphate for treating acute asthma Population
Studies Included: Ciarallo 1996, Devi 1997, Gurkan 1999, Ciarallo 2000, Scarfone 2000. Inclusion Criteria: Controlled clinical trials of Ivmag of any dose, age <18 years.
Asthma Severity
Interventions
Treatment: No limitation on treatment, predominantly 2g max of Ivmag, except for Scarfone 2000 which used a 2.5g max.
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Pooled point estimate = 0.290 (95%CI 0.143-0.589) p=0.0006; Qtest of heterogeneity Pooled point estimate = 0.155 (95%CI 0.057 to 0.422) p=0.0003; Qtest of heterogeneity Pooled point estimate = 8.58 (95%CI 0.94 to Difference in % improvement of PEFR at end of 16.22) p=0.028; Qtest of heterogeneity study Pooled point estimate = 1.33 (95%CI 0.31 to Difference in clinical symptom score at end of Evidence Table for IV Magnesium Treatment for Asthma Intravenous and nebulised magnesium sulphate for acute asthma: systematic review and meta-analysis Studies Included: Bijani 2002, Silverman 2002, Porter 2001, Bilaceroglu 2001 (not analyzed), Boonyavorakul 2000, Scarfone 2000, Ciraallo 200, Gurkan 1999, Devi 1997,
Cirallo 1996, Bloch 1995, Matusiewicz 1994 (not analyzed), Tiffany 1993, Green 1992, Skoboleff 1989. Age = range 1-85, Gender (% female) = range 23%-88%, Ethnicity
Population
Asthma Severity
Interventions
Treatment: Predominantly 2g max of Ivmag, except Scarfone 2000 (2.5g max), Skobeloff (1.2g max), Mastusiewicz (1.2g max).
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SMD (random) 0.25 (95%CI -0.01 to 0.51); test for heterogeneity x2=27.20, df=8 (p=.0007), i2=70.6^; Test for overal effect Effects of Ivmag on respiratory function - adult SMD (random) 1.94 (95%CI 0.80-3.08); Test for heterogeneity: x2=19.26, df=3 (p=0.0002), Effects of Ivmag on respiratory function - i2=84.4%; Test for overall effect: z=3.34 SMD (random) 0.61 (95%CI 0.26 to 0.96); Test for heterogeneity: x2=76.66, df=12 (p<0.00001), i2=84.3%; Test for overall effect: Effects of Ivmag on respiratory function - total RR (random) 0.87 (95%CI 0.70 to 1.08); Test for heterogeneity: x2=9.99, df=7 (p=0.19), i2=30.0%; Test for overall effect: z=1.23 Effects of Ivmag on hospital admission - adult RR (random) 0.70 (95%CI 0.54-0.90); Test for heterogeneity: x2=2.16, df=2 (p=0.34); Effects of Ivmag on respiratory function - i2=7.3%; Test for overall effect: z=2.81 RR (random) 0.81 (95%CI 0.67-0.97); Test for heterogeneity: x2=16.02, df=10 (p=0.10), i2=37.6%; Test for overall effect: z=2.30 Effect of Ivmag on hospital admission - total Evidence Table for IV Magnesium Treatment for Asthma Magnesium sulfate for treating exacerbations of acute asthma in the emergency department The Cochrane Database of Systematic Reviews Studies Included: Bloch 1995, Ciarallo 1997, Devi 1997, Green 1992, Skobeloff 1989, Silberman 1996, Tiffany 1993. Inclusion Criteria: RCT/quasi-RCT, children or adult
Population
patients presenting to EDs for acute asthma therapy/management Asthma Severity
Treatment: Patients randomized to receive Ivmag or placebo in ED treatment. Co-interventions/therapies: beta-agonist (all studies), theophyllie administration up to physician
Interventions
(except for in two studies), ICS therapy common in studies (Bloch 1995 providing ICS in most severe cases).
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OR 0.31 (95%CI 0.09-1.02); significant heterogeneity - chi-squared=19.53, df=5; OR 0.10 (95%CI 0.04 to 0.27); heterogeneity - Admission to hospital - severe asthma subgroup chi-sqaured =0.26; df=3; p>0.1 Admission to hospital - mild-moderate asthma OR 1.36 (94%CI (stated as 94%) 0.72-2.55) WMD 29.4 (95%CI -3.4 to 62) statistically significant heterogeneity: chi-sqaured =9.7, WMD 4.3 (95%CI - -2.3 to 10.9) statistically significant heterogeneity: chi-squared = 7.47; Evidence Table for IV Magnesium Treatment for Asthma Controlled study on intravenous magnesium sulfate or salbutamol in early treatment of severe acute asthma attack in children 50 patients (17 Mg; 17 salbutamol; 16 placebo) Population Description: Children (>2 yo), with severe acute asthma admitted for observation. Exclusion Criteria: Other pulmonary or cardiac pathology on admission,
known family history of supraventricular tachycardia, diabetes mellitus, glucose intolerance, collection delay of pre-established laboratory exams, delayed study drug
Population
administration, significant deterioration (transfer to ICU), immediate endotracheal intubation, no consent. Mean age = 4.5, Gender = 53% female, Ethnicity = N/A
Asthma Severity
Standard of Care: Oxygen, corticosteroids, beta-adrenergics (all given equal dosages at equal intervals). Treatment: 3 options - 1) IVMg (2.5mg/kg/min for 20min - 2gmax) 2)
Interventions
intravenous salbutamol (1ug/kg/min) c) saline solution.
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6.12+-2.47 Mg; 4.65+-3.10 sal; 6.56 +-3.67 No Deductions No Deductions No Deductions 4.24+-2.22 Mg; 2.71+-1.19 sal;4.44+-2.34 5.88+-2.34 Mg; 4.06+-2.25 sal; 5.81+-2.83 2.71+-2.57 Mg; 1.71+-1.86 sal; 2.88+-3.12 Length of stay in Pediatric Intensive Care Unit Evidence Table for IV Magnesium Treatment for Asthma Lack of Effectiveness of Magnesium in Chronic Stable Asthma 15 patients with chronic stable asthma, 10 nonasthmatics Population Description: Patients (18-45 yo) with chronic stable asthma/normal subjects. Exclusion Criteria: Treatment with steroids (<2 weeks prior to study), treatment
Population
with tapering doses of steroids, renal dysfunction. Mean age = 30.3+-2.2 Mg, 30.7+-1.7 normal, Gender = 46.6% male Mg; 90% male normal, Ethnicity = N/A
Asthma Severity
Study Design: Day 1 - spirometry and albuterol challenge to confirm asthma via ATS definition; Day 2 - subjects received Ivmag (2g) or placebo, Day 3 - subjects crossed to
Interventions
Inconsistent Indirectness of
Publication
Study Design
Limitations
Evidence
Imprecision
Quality Rating
Improvements in FEV1 in asthmatic/normal No Deductions No Deductions No Deductions Improvements in FVC in asthmatic/normal subjects Improvements in Maximum FEF in asthmatic/normal subjects New Evidence Table for IV Magnesium Treatment for Asthma A Randomized Controlled Trial of Intravenous Magnesium Sulphate as an Adjunct to Standard Therapy in Acute Severe Asthma 75 patients screened (15 excluded) 60 participants (30 IV magnesium sulphate) (30 control) Description: Patients presenting to ER with acute asthma. Inclusion Critieria: physician diagnosed demonstrating 12% reversibility, and on medication last 6 months, FEV1 <30% predicted
when presenting to ED, fulfilled most of the GINA criteria for a severe asthmatic exacerbation. Exclusion Criteria: History of COPD or other chronic lung disease or cardiac, renal or hepatic
abnormalities, pregnant or lactating, requiring intubation or unable to perform spirometry. Age = Treatment group 34.79 (8.05), control group 35.9 (8.76), Gender = Treatment group 47% male,
Population
control group 50% male, Ethnicity =N/A
Asthma Severity
Standard of Care: 100mg of IV hydrocortisone, a nebulizing solution consisting of 2.5mg of B2-agonist, 1.5ml of ipratropium bromide and 2.5 ml of normal saline, 100% oxygen at 0, 20, and 40
minutes after admission into protocol. Treatment: At 30 min, 2g of magnesium sulphate in 250 ml normal saline given over 20 minutes. Control: At 30 min, placebo in 250 ml normal saline
Interventions
Inconsistent Indirectness
Publication
Study Design
Limitations
of Evidence
Imprecision
Quality Rating
At arrival - 22.0(SD 5.1) placebo, 22.07 (SD 4.77) IV mag; At 120 minutes (Discharge) - 56.70 (SD 6.20) placebo, 62.84 (SD 10.02) IV mag; Mean difference between groups (95%CI) = 6.07 (1.87-10.62); p=0.01 Hospital Admission at 2 9/30 Placebo; 2/30 IV MgSO4; p=0.011; OR for admission (IVMag vs. hours Articles/Abstracts Not Analyzed:
1) Bilaceroglu S, Akpinar M, Tiras A, et al. Intravenous magnesium sulphate in acute asthma. Annual Thoracic Society 97th International Conference. San Francisco, 18-23 May, 2001 2) Matusiewicz SP, Cusack S, Greening AP, et al. A double blind placebo controlled parallel group study of intravenous magnesium sulphate in acute severe asthma. Eur Respir J 1994; 7(Suppl 18): 14s

Source: http://www.ginasthma.org/local/uploads/content/files/GRADE_MgSO4.pdf