What injectable steroid is recommended for an asthma flare?

Injectable Steroid for Asthma Flare

Intravenous hydrocortisone 200 mg is the recommended injectable steroid for an asthma flare. 1

Dosing and Administration

For patients with acute severe asthma requiring injectable steroids, the following regimen is recommended:

• First-line injectable steroid: Hydrocortisone 200 mg IV every six hours for patients who are seriously ill or vomiting 1
• Alternative option: Methylprednisolone 1-2 mg/kg/day IV (maximum 60 mg/day) 2

Treatment Algorithm for Asthma Flare

1. Assessment of severity:

   • Severe asthma: Too breathless to complete sentences, respiratory rate >25/min, PEF <50% predicted, heart rate >110/min
   • Life-threatening: PEF <33% predicted, silent chest, cyanosis, bradycardia/hypotension, exhaustion/confusion 1

2. Initial management:

   • High-dose inhaled β-agonists (salbutamol 5 mg or terbutaline 10 mg nebulized)
   • Injectable steroid: Hydrocortisone 200 mg IV immediately 1

3. For life-threatening features:

   • Add nebulized ipratropium (0.5 mg)
   • Consider IV aminophylline or IV salbutamol/terbutaline 1

4. Ongoing management:

   • Continue IV hydrocortisone 200 mg every six hours in seriously ill patients
   • For improving patients, transition to oral prednisolone 30-60 mg daily 1

Monitoring and Follow-up

• Measure peak expiratory flow 15-30 minutes after starting treatment and regularly thereafter
• Continue oxygen therapy as needed
• For improving patients, give nebulized β-agonist every four hours
• For non-improving patients after 15-30 minutes, increase frequency of nebulized β-agonists 1

Special Considerations

• Systemic corticosteroids should be administered early in the exacerbation to reduce hospitalization risk 2
• Even short courses of systemic corticosteroids can cause adverse effects including mental health impacts, hypertension, and gastrointestinal issues 2
• In children, methylprednisolone may be dosed at 1-2 mg/kg/day (maximum 60 mg/day) 2

Common Pitfalls to Avoid

1. Delayed administration: Delaying corticosteroid administration can slow resolution of airflow obstruction and increase hospitalization rates 2

2. Inadequate monitoring: Failure to monitor peak flow and clinical response can miss deterioration requiring escalation of therapy 1

3. Premature discharge: Patients should not be discharged until symptoms have stabilized with peak expiratory flow above 75% of predicted value 1

4. Inappropriate sedation: Any sedation is contraindicated in acute asthma 1

5. Overuse of antibiotics: Give antibiotics only if bacterial infection is present 1

While some studies have explored intramuscular methylprednisolone as an alternative 3, the British Thoracic Society guidelines clearly recommend intravenous hydrocortisone as the injectable steroid of choice for acute severe asthma flares requiring hospitalization 1.