When is prednisone indicated for cough-related illnesses in elderly patients?

Prednisone Use for Cough-Related Illnesses in Elderly Patients

Prednisone should only be prescribed for elderly patients with cough when specific conditions are present, including severe postinfectious cough that persists despite other treatments, cough variant asthma, or when the cough significantly impacts quality of life after other common causes have been ruled out. 1, 2

Appropriate Indications for Prednisone in Cough

Postinfectious Cough

• Consider prednisone (30-40 mg daily) for short, finite periods only when:
  • Cough persists and becomes troublesome despite other treatments
  • Cough adversely affects quality of life
  • Other common causes of cough (upper airway cough syndrome, asthma, GERD) have been ruled out 1
  • First-line therapies like inhaled ipratropium have failed 2

Cough Variant Asthma

• Diagnostic trial of prednisone (30 mg daily for 1-2 weeks) may be used to establish diagnosis 3
• If responsive, transition to inhaled corticosteroids for long-term management 1, 3
• Follow national asthma guidelines for management after diagnosis 1

Conditions Where Prednisone is NOT Indicated

• Acute viral respiratory infections 4
• Uncomplicated acute bronchitis 1
• Pertussis infection (whooping cough) 1
• Non-asthmatic acute lower respiratory tract infections 4

Evaluation Before Starting Prednisone

1. Determine cough duration:

   • Acute: <3 weeks
   • Subacute: 3-8 weeks
   • Chronic: >8 weeks 2

2. Rule out common causes requiring specific treatments:

   • Upper airway cough syndrome (treated with antihistamine/decongestant)
   • GERD (treated with PPIs and lifestyle modifications)
   • Medication-induced cough (e.g., ACE inhibitors)
   • Lung cancer or other malignancies 2

3. Consider chest radiograph to rule out serious pathology 2

Prednisone Dosing and Duration

• For postinfectious cough: 30-40 mg daily, tapering over 2-3 weeks 1
• For diagnostic trial in suspected cough variant asthma: 30 mg daily for 1-2 weeks 3
• Shorter courses are preferred in elderly patients to minimize adverse effects

Cautions in Elderly Patients

• Monitor for steroid-induced complications:
  • Hyperglycemia/diabetes exacerbation 5
  • Hypertension
  • Increased risk of infections
  • Bone density loss
  • Fluid retention
  • Mood changes
  • Sleep disturbances

Alternative Treatments to Consider First

• Inhaled ipratropium bromide for postinfectious cough 1, 2
• Inhaled corticosteroids for suspected asthma or eosinophilic bronchitis 1, 2
• Central-acting antitussives (codeine, dextromethorphan) when other measures fail 1, 2
• First-generation antihistamines for upper airway cough syndrome 2

Follow-up and Monitoring

• Re-evaluate if cough persists beyond 4-6 weeks of appropriate treatment 2
• Consider specialist referral if:
  • Cough persists despite appropriate treatment
  • Suspicion of serious underlying pathology
  • Significant impact on quality of life 2

Remember that a randomized clinical trial showed oral corticosteroids did not reduce symptom duration or severity in non-asthmatic adults with acute lower respiratory tract infection 4, so their use should be restricted to specific indications where evidence supports benefit.