Should I start a short course of steroids in an asthma patient along with bronchodilators?

Short Course of Steroids in Asthma Exacerbations

A short course of oral steroids should be started immediately along with bronchodilators in patients experiencing an asthma exacerbation, as this significantly reduces morbidity, mortality, and relapse rates. 1, 2

Assessment of Exacerbation Severity

Before initiating treatment, quickly assess the severity of the exacerbation:

Classification	Symptoms	PEF Value
Mild	Mild symptoms, no limitation of activities	≥80% of predicted or personal best
Moderate	Worsening symptoms, some limitation	50-79% of predicted or personal best
Severe	Significant symptoms, significant limitation	<50% of predicted or personal best
Life-threatening	Severe symptoms, inability to speak, cyanosis	<25% of predicted or personal best

Treatment Protocol

First-Line Treatment:

1. Short-acting bronchodilators (e.g., salbutamol/albuterol) via metered-dose inhaler with spacer or nebulizer
2. Oral corticosteroids - Prednisolone 30-60 mg daily for adults 1, 2

Steroid Dosing:

• Adults: Prednisolone 30-40 mg daily until lung function returns to previous best (typically 7 days, but may need up to 21 days) 1
• Short courses (up to two weeks) of oral steroids do not need to be tapered; they can be stopped from full dosage 1

Rationale for Using Oral Steroids

1. Proven efficacy: Steroid treatment provides important benefits to patients with acute exacerbations of asthma 1
2. Reduced relapse rates: Patients receiving corticosteroids have significantly fewer relapses requiring additional care (odds ratio 0.35) 3
3. Decreased bronchodilator use: Patients on steroids need less beta-agonist use (approximately 3.3 fewer activations per day) 3
4. Early intervention: Deterioration of asthma may be a marker of destabilization requiring anti-inflammatory treatment 4

Important Considerations

• Timing is critical: Administer systemic corticosteroids within the first hour of treatment for best results 2
• Route of administration: Oral administration is preferred in most cases; intravenous administration offers no advantages unless the patient cannot take oral medications 1
• Monitor response: Measure Peak Expiratory Flow (PEF) 15-30 minutes after starting treatment to assess response 2
• Warning signs: If the patient needs more doses of bronchodilator than usual, this may indicate destabilization of asthma requiring re-evaluation and consideration of anti-inflammatory treatment 4

Discharge Planning

When discharging a patient after treatment:

• Ensure they've been on discharge medication for 24 hours with proper inhaler technique
• Verify PEF >75% of predicted/best with diurnal variability <25%
• Provide treatment with oral steroids and inhaled steroids in addition to bronchodilators
• Arrange follow-up with primary care within 1 week 1, 2

Potential Side Effects of Short-Course Steroids

Short courses of systemic corticosteroids are generally well-tolerated with minimal side effects 5. However, be aware of:

• Reversible abnormalities in glucose metabolism
• Increased appetite
• Mood alterations
• Very low rates of gastrointestinal bleeding (greatest risk in patients with history of GI bleeding or taking anticoagulants) 1

Cautions

• Inhaled corticosteroids alone should not be used routinely to treat acute exacerbations 6
• Delaying corticosteroid administration can lead to worse outcomes 2
• Underestimating severity based on clinical appearance alone should be avoided 2

By following this approach, you can effectively manage asthma exacerbations while minimizing the risk of relapse and complications.