Is it advisable to send steroids home with a patient discharged with a diagnosis of bronchial asthma not in acute exacerbation?

Management of Steroids in Discharged Bronchial Asthma Patients

Patients discharged with a diagnosis of bronchial asthma not in acute exacerbation should NOT be routinely prescribed systemic corticosteroids to take home, but should be prescribed inhaled corticosteroids as maintenance therapy.

Rationale for Steroid Management

Systemic Corticosteroids

• Systemic corticosteroids (oral prednisone/prednisolone) are only indicated for:

  • Patients recovering from an acute exacerbation (3-10 days course)
  • Not for stable asthma without recent exacerbation 1

• The National Asthma Education and Prevention Program Expert Panel clearly states that systemic corticosteroids should only be prescribed for 3-10 days after discharge from an acute exacerbation 1

• There is no evidence supporting the use of long-term systemic corticosteroids to reduce acute exacerbations of asthma, and the risks of hyperglycemia, weight gain, infection, osteoporosis, and adrenal suppression far outweigh any benefits 1

Inhaled Corticosteroids

• Inhaled corticosteroids (ICS) are the fundamental first-line therapy for ongoing asthma management due to their proven effectiveness and minimal systemic adverse effects 1, 2

• The Expert Panel recommends that clinicians consider initiating inhaled corticosteroids at discharge in patients not already receiving them 1

• Patients who are currently receiving inhaled corticosteroid therapy should continue this treatment while taking systemic corticosteroids (if prescribed for acute exacerbation) 1

Discharge Medication Protocol

For Patients NOT in Acute Exacerbation:

1. Maintenance therapy: Prescribe appropriate inhaled corticosteroid (ICS) based on asthma severity 2

   • Mild asthma: Low-dose ICS-formoterol as needed or daily low-dose ICS
   • Moderate asthma: Low-dose ICS-formoterol as maintenance and reliever
   • Severe asthma: High-dose ICS plus LABA

2. Rescue medication: Short-acting beta-agonist (SABA) as needed for symptom relief 2

3. NO systemic steroids should be prescribed for patients with stable asthma not in exacerbation 1

For Patients Recovering from Recent Exacerbation:

1. Prescribe systemic corticosteroids (prednisone 40-60 mg daily) for a short course of 3-10 days 1

2. Continue or initiate inhaled corticosteroids as maintenance therapy 1

3. Provide rescue medication (SABA) for symptom relief 2

Follow-up Recommendations

• Schedule follow-up appointment to evaluate the need for additional corticosteroid treatment 1

• Provide patient education on:

  • Correct inhaler technique 1
  • Written asthma action plan for managing recurrence of symptoms 1, 2
  • Monitoring of symptoms and when to seek medical help 2

Common Pitfalls to Avoid

1. Overuse of systemic corticosteroids: Long-term use leads to significant adverse effects including hyperglycemia, weight gain, infection, osteoporosis, and adrenal suppression 1, 3

2. Undertreatment with inhaled corticosteroids: ICS are the most effective anti-inflammatory agents for asthma control and should be the cornerstone of maintenance therapy 4

3. Lack of patient education: Patients should understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory treatment) 1

4. No written action plan: All patients should receive a written plan for managing worsening symptoms 1, 2

By following these evidence-based guidelines, clinicians can optimize asthma management, reduce the risk of exacerbations, and minimize the adverse effects associated with unnecessary systemic corticosteroid use.