What is the next step in managing an asthma exacerbation that is unresponsive to a 5-day course of corticosteroids (steroids)?

From the Guidelines

For asthma exacerbation not responding to a 5-day course of steroids, intensify treatment as follows: extend oral prednisone course to 10-14 days, typically 40-60 mg daily, and increase inhaled corticosteroid dose, as recommended by the National Asthma Education and Prevention Program expert panel report 3 guidelines for the management of asthma exacerbations 1.

Key Recommendations

• Extend oral prednisone course to 10-14 days, typically 40-60 mg daily, as there is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 1.
• Increase inhaled corticosteroid dose, e.g., fluticasone 500 mcg twice daily, as inhaled corticosteroids are the most potent and consistently effective long-term control medication for asthma 1.
• Add a long-acting beta-agonist (LABA) if not already using one, such as salmeterol or formoterol, as combining long-acting beta agonists and inhaled corticosteroids is effective and safe when inhaled corticosteroids alone are insufficient 1.
• Ensure proper inhaler technique and adherence to medication regimen, as addressing potential issues with inhaler technique ensures optimal medication delivery.
• Consider adding a leukotriene receptor antagonist like montelukast 10 mg daily, as leukotriene receptor antagonists can provide additional anti-inflammatory effects, although they are not the preferred adjunctive therapy when compared with the addition of long-acting beta2 agonists 1.
• Use short-acting beta-agonist (e.g., albuterol) as needed for symptom relief, and monitor peak flow measurements closely, as increasing the use of short-acting beta agonists or using them more than two days per week generally indicates inadequate control of asthma and the need to initiate or intensify anti-inflammatory therapy 1.

Rationale

The extended steroid course and increased inhaled corticosteroid dose help to further reduce airway inflammation. Adding a LABA provides prolonged bronchodilation. Addressing potential issues with inhaler technique ensures optimal medication delivery. Leukotriene receptor antagonists can provide additional anti-inflammatory effects. Close monitoring allows for timely adjustments to treatment if needed. If no improvement after these steps, consider hospitalization for IV steroids and closer monitoring, as recommended by the National Asthma Education and Prevention Program expert panel report 3 guidelines for the management of asthma exacerbations 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Managing Asthma Exacerbation Unresponsive to Corticosteroids

• The next step in managing an asthma exacerbation that is unresponsive to a 5-day course of corticosteroids is not explicitly stated in the provided studies 2, 3, 4, 5, 6.
• However, the studies suggest that corticosteroids are effective in reducing the risk of asthma exacerbations 2, 3.
• A study found that a short course of corticosteroids following assessment for an acute exacerbation of asthma significantly reduces the number of relapses to additional care and decreases beta-agonist use without an apparent increase in side effects 3.
• Another study suggests that steroid tapering is unnecessary in acute asthma, and a personal asthma management plan with a reserve course of prednisolone may be more appropriate 4.
• The optimal dosing of oral steroids for asthma exacerbations to maximize recovery while minimizing potential side effects is still unclear, and evidence is limited 5.
• Stopping long-acting beta2-agonists (LABA) in adults with well-controlled asthma may increase the likelihood of asthma exacerbations that require treatment with oral corticosteroids, but this is not certain 6.

Key Considerations

• The effectiveness of corticosteroids in reducing the risk of asthma exacerbations 2, 3
• The potential benefits and drawbacks of steroid tapering in acute asthma 4
• The need for further research to determine the optimal dosing of oral steroids for asthma exacerbations 5
• The potential risks and benefits of stopping LABA in adults with well-controlled asthma 6