Steroid Dosing for Asthma Exacerbations
For asthma exacerbations, oral prednisolone 30-60 mg daily or intravenous hydrocortisone 200 mg every six hours is recommended, with the duration based on severity and response to treatment. 1, 2
Dosing Recommendations by Severity
Moderate to Severe Exacerbations
- Adults: Prednisolone 40-60 mg daily for 5-10 days 1, 2
- Children: Prednisolone 1-2 mg/kg/day (maximum 60 mg) for 3-10 days 1, 2
- IV alternative: Hydrocortisone 200 mg every 6 hours for seriously ill patients or those who cannot take oral medications 1
Life-Threatening Exacerbations
- Consider both oral prednisolone AND intravenous hydrocortisone 200 mg immediately 1
- Continue IV steroids until significant clinical improvement occurs
Key Clinical Considerations
Administration
- Oral administration is as effective as intravenous for most patients 2
- No need to taper for courses less than 5-10 days 1, 2
- For patients who are vomiting or unable to take oral medications, use IV hydrocortisone 200 mg every 6 hours 1
Duration of Treatment
- Standard duration is 5-10 days for most exacerbations 2
- Evidence suggests that 5 days may be as effective as 10 days when patients are also receiving inhaled corticosteroids 3
- For mild-to-moderate exacerbations, particularly in children, a single dose of dexamethasone may be an alternative to multiple days of prednisolone 4
Monitoring Response
- Measure peak expiratory flow (PEF) 15-30 minutes after starting treatment and thereafter according to response 1, 2
- Continue steroids until PEF reaches 70% of predicted or personal best 2
- Monitor for clinical improvement in symptoms, respiratory rate, and oxygen saturation
Common Pitfalls to Avoid
Underdosing: Using less than 30 mg of prednisolone daily may be insufficient for controlling inflammation in acute exacerbations 1, 5
Delayed administration: Systemic steroids should be given immediately in moderate to severe exacerbations, not delayed while waiting for response to bronchodilators 1, 2
Premature discontinuation: Continue steroids until adequate clinical improvement is achieved 2
Unnecessary tapering: Short courses (5-10 days) generally don't require tapering 1, 2
Relying solely on steroids: Always use in conjunction with bronchodilators (β-agonists) and consider adding ipratropium for severe exacerbations 1, 2
Special Populations
- Pregnant women: Same dosing applies; benefits outweigh risks 2
- Diabetics: Monitor blood glucose closely as steroids will cause elevation 2
- Patients on maintenance oral steroids: Increase dose to treatment level during exacerbations 1
While there is some evidence that lower doses might be effective 5, the most recent guidelines consistently recommend prednisolone 40-60 mg daily for adults with moderate to severe exacerbations to prevent mortality and reduce morbidity 1, 2.