What is the recommended prednisone (corticosteroid) tapering dosing schedule for patients with asthma?

Prednisone Taper Dosing for Asthma Exacerbations

For asthma exacerbations, a short course of prednisone 40-60 mg daily for 5-10 days without tapering is recommended as it is as effective as tapered regimens while being simpler to administer. 1

Initial Dosing for Acute Exacerbations

Adults

• Initial dose: Prednisone 40-60 mg daily for 5-10 days
• No tapering necessary for short courses (less than 10-14 days) 1
• For outpatient management of moderate exacerbations: 40-60 mg/day 2
• For severe exacerbations: Initial dosing of 120-180 mg/day in 3-4 divided doses for 48 hours, then 60-80 mg/day until peak expiratory flow (PEF) reaches 70% of predicted or personal best 2

Children

• 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 2
• For severe exacerbations: 1-2 mg/kg every 6 hours for 48 hours, then 1-2 mg/kg/day (maximum 60 mg/day) in 2 divided doses until PEF is 70% of predicted or personal best 2

Evidence Against Routine Tapering

Multiple studies have demonstrated that short courses of systemic corticosteroids without tapering are as effective as tapered regimens:

• Non-tapering regimens show no significant difference in relapse rates compared to tapering regimens 3, 4
• Short courses of prednisone (8 days) without tapering showed no difference in adrenal suppression compared to tapering regimens 4
• Oral administration is as effective as intravenous administration for moderate to severe exacerbations 1

When Tapering May Be Considered

While most patients do not require tapering, consider tapering in the following situations:

1. Patients who have been on systemic corticosteroids for more than 2 weeks
2. Patients who have received multiple courses of systemic corticosteroids in the past year
3. Patients with known hypothalamic-pituitary-adrenal axis suppression
4. Patients with severe or "steroid-resistant" asthma who require higher doses 2

Monitoring During Treatment

• Measure and record peak expiratory flow 15-30 minutes after starting treatment and thereafter according to response 2
• Continue high doses of steroids (prednisolone 30-60 mg daily) until clinical improvement 2
• Patients should not be discharged until symptoms have stabilized with PEF above 75% of predicted value or personal best 2

Discharge Planning

• Ensure proper inhaler technique is demonstrated
• Provide a written asthma action plan
• Arrange follow-up with primary care within 1 week 1
• Consider adding inhaled corticosteroids upon discharge to reduce the risk of relapse 1, 5

Common Pitfalls to Avoid

1. Unnecessary tapering: For short courses (5-10 days), tapering is not necessary and adds complexity without benefit 1, 3

2. Inadequate initial dosing: Underdosing systemic corticosteroids may lead to incomplete resolution and early relapse 5

3. Prolonged steroid courses: Extending systemic steroid use beyond what is necessary increases risk of adverse effects without additional benefit

4. Failure to transition to inhaled corticosteroids: Patients should be started or continued on inhaled corticosteroids when oral steroids are discontinued 1

5. Missing steroid-resistant asthma: Some patients may require higher doses or longer courses due to reduced steroid responsiveness 2

The evidence strongly supports using short courses of prednisone without tapering for most asthma exacerbations, which simplifies treatment while maintaining efficacy and minimizing side effects.