Recommended Corticosteroid Dosing for Asthma Exacerbations
For adults with asthma exacerbations, the recommended initial dose of systemic corticosteroids is 40-80 mg/day of prednisone (or equivalent) until peak expiratory flow reaches 70% of predicted or personal best. 1
Adult Dosing
- Prednisone: 40-80 mg/day in 1 or 2 divided doses until PEF reaches 70% of predicted or personal best 1
- For outpatient "burst" therapy: 40-60 mg in single or 2 divided doses for a total of 5-10 days 1
- Methylprednisolone: equivalent dosing (approximately 32-64 mg/day) 2
Pediatric Dosing
- Children: 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) until PEF is 70% of predicted or personal best 1
- For outpatient "burst" therapy: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1
Route of Administration
- No advantage has been demonstrated for intravenous administration over oral therapy provided gastrointestinal absorption is not impaired 1, 3
- Oral administration is preferred when patients can tolerate it 3, 4
- A randomized controlled study showed that oral prednisolone (100 mg daily) was as effective as intravenous hydrocortisone (100 mg every 6 hours) in improving peak expiratory flow rate in adults with acute asthma exacerbations 4
Duration of Therapy
- The total course of systemic corticosteroids for an asthma exacerbation requiring an ED visit or hospitalization typically lasts from 3 to 10 days 1
- For corticosteroid courses of less than 1 week, there is no need to taper the dose 1
- For slightly longer courses (up to 10 days), there probably is no need to taper, especially if patients are concurrently taking inhaled corticosteroids 1
Important Clinical Considerations
- Higher doses of corticosteroids have not shown additional benefit in severe asthma exacerbations 1, 5
- A study comparing low (50 mg), medium (100 mg), and high (500 mg) doses of intravenous hydrocortisone every 6 hours showed no significant difference in effectiveness 5
- Inhaled corticosteroids should not replace systemic corticosteroids for acute exacerbations, particularly in more severe cases 6
- Systemic corticosteroids should be administered early in the treatment of acute exacerbations, as their anti-inflammatory effects may take 6-12 hours to become apparent 3
Pitfalls to Avoid
- Delaying administration of systemic corticosteroids during acute exacerbations can lead to poorer outcomes 3
- Using only inhaled corticosteroids for moderate to severe exacerbations is insufficient 6
- Unnecessarily high doses of corticosteroids increase risk of adverse effects without providing additional clinical benefit 1, 5
- Tapering short courses (less than 7 days) of corticosteroids is unnecessary and may lead to underdosing during the critical period 1