What is the recommended corticosteroid (CS) treatment for asthma exacerbation?

Corticosteroid Treatment for Asthma Exacerbations

For asthma exacerbations, systemic corticosteroids should be administered promptly, with oral prednisone (or equivalent) as the preferred first-line treatment for most patients, given at a dose of 40-60mg daily for 3-10 days without tapering. 1

Systemic Corticosteroid Recommendations

Route of Administration

• Oral administration is preferred for most patients due to equivalent efficacy to intravenous route with less invasiveness 1
• Intravenous administration should be reserved for patients who cannot take oral medications or have severe exacerbations 1, 2
• For those at high risk of non-adherence, intramuscular depot injections may be considered as an alternative 1

Dosing Guidelines

• Adult dosing: 40-60mg of prednisone (or equivalent) daily 1, 2
• Pediatric dosing: 1-2 mg/kg/day of prednisone, prednisolone, or methylprednisolone 2
• Duration: 3-10 days is typically sufficient 1
• Tapering is generally not necessary for short courses of therapy 2

Timing of Administration

• Early administration of systemic corticosteroids is crucial as it speeds resolution of airflow obstruction and reduces post-ED relapse rates 1
• For moderate to severe exacerbations, administer corticosteroids within the first hour of treatment 1

Severity-Based Treatment Approach

Mild Exacerbations

• Oral corticosteroids may be indicated, especially if response to initial bronchodilator therapy is inadequate 1
• Five guidelines recommend oral corticosteroids even for mild exacerbations 1

Moderate Exacerbations

• Oral corticosteroids are strongly recommended (11 guidelines support this approach) 1
• Should be administered early in treatment course 1

Severe Exacerbations

• Systemic corticosteroids are essential components of treatment 1
• Intravenous administration may be preferred in patients with potential absorption issues 1, 2
• Seven guidelines specifically recommend IV corticosteroids for severe exacerbations 1

Additional Treatment Considerations

Concurrent Medications

• Systemic corticosteroids should be used alongside inhaled β2-agonists and oxygen as appropriate 1
• Patients already on inhaled corticosteroids should continue this therapy while taking systemic corticosteroids 1
• Consider adding ipratropium bromide for additional bronchodilation, particularly in severe exacerbations 1

Post-Discharge Management

• Prescribe sufficient medication to continue therapy for 3-10 days after discharge 1
• Consider initiating or continuing inhaled corticosteroids at discharge 1
• Schedule follow-up appointment to assess need for additional corticosteroid treatment 1

Common Pitfalls and Caveats

• Delaying corticosteroid administration can worsen outcomes and increase hospitalization rates 1
• Unnecessarily prolonged courses (>10 days) do not provide additional benefit and increase risk of side effects 1, 2
• Tapering short courses (5-10 days) of systemic corticosteroids is unnecessary and does not prevent relapse 2
• Relying solely on inhaled corticosteroids during acute exacerbations is insufficient; systemic therapy is required 1
• Antibiotics should not be routinely prescribed unless there is strong evidence of bacterial infection 1

Special Populations

• Pregnant patients: Uncontrolled asthma poses greater risk than corticosteroid treatment; use lowest effective dose 1
• Pediatric patients: Dosing should be based on severity rather than age, typically 1-2 mg/kg/day 2
• Patients with diabetes: Monitor blood glucose levels closely as corticosteroids can cause hyperglycemia 2