What is the best prednisone (corticosteroid) regimen for managing acute asthma exacerbations?

Best Prednisone Regimen for Acute Asthma Exacerbations

For acute asthma exacerbations, prednisolone 30-40 mg daily should be given until lung function returns to the patient's previous best, typically requiring 7 days of treatment but potentially needing up to 21 days in more severe cases. 1

Dosing and Duration Guidelines

Initial Treatment

• Dose: Prednisolone 30-40 mg daily (oral administration) 1
• Route: Oral administration is preferred as intravenous administration offers no advantages 1
• Duration: Continue until lung function values return to previous best 1
  • Typically 7 days is sufficient for most patients
  • May need up to 21 days in more severe cases

Alternative Regimens

• Short-course option: 2 days of oral dexamethasone 16 mg daily has been shown to be at least as effective as 5 days of prednisone for returning patients to normal activity levels 2
• Low-dose option: Research shows that lower doses of hydrocortisone (50 mg IV every 6 hours) followed by low-dose oral prednisone can be as effective as higher doses in resolving acute severe asthma 3

Assessment of Severity

Features of Acute Severe Asthma 1

• Cannot complete sentences in one breath
• Respiratory rate >25 breaths/min
• Pulse >110 beats/min
• PEF <50% of predicted or best

Life-Threatening Features 1

• PEF <33% of predicted normal or best
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma

Treatment Algorithm

1. Initial assessment:

   • Measure PEF to determine severity
   • Assess for features of severe or life-threatening asthma

2. For mild to moderate exacerbations (PEF >50% predicted):

   • Prednisolone 30-40 mg daily
   • Nebulized salbutamol 5 mg or terbutaline 10 mg
   • Monitor response after 15-30 minutes

3. For severe exacerbations (PEF <50% predicted):

   • Prednisolone 30-60 mg daily or IV hydrocortisone 200 mg
   • Oxygen 40-60% if available
   • Nebulized salbutamol 5 mg or terbutaline 10 mg
   • Consider hospital admission if features persist after treatment

4. Duration of treatment:

   • Continue prednisolone until PEF returns to previous best
   • No need to taper dose for courses up to two weeks 1

Important Clinical Considerations

• When used in short courses (up to two weeks), oral steroids can be stopped from full dosage without tapering 1
• Oral administration is preferred over IV administration 1
• Risk of gastrointestinal bleeding is very low with short courses of steroids; greatest risk is in patients with history of GI bleeding or those taking anticoagulants 1
• Monitoring response to treatment is essential - PEF should be measured 15-30 minutes after starting treatment and thereafter according to response 1
• Follow-up within 48 hours is recommended for patients treated at home 1

Criteria for Hospital Admission 1

• Any life-threatening features
• Features of acute severe asthma persisting after initial treatment
• PEF <33% of predicted after initial treatment

Common Pitfalls to Avoid

1. Underestimating severity: Many deaths from asthma are preventable and often result from failure to assess severity objectively 1
2. Inadequate steroid dosing: Underuse of corticosteroids is a factor in preventable asthma deaths 1
3. Premature discontinuation: Stopping treatment before lung function has returned to baseline can lead to relapse
4. Unnecessary tapering: Short courses (up to 2 weeks) do not require tapering 1
5. Inadequate follow-up: All patients should have follow-up within 48 hours after an acute exacerbation 1