Is prednisolone (corticosteroid) effective for treating a cough?

Prednisolone for Cough: Evidence-Based Recommendations

Prednisolone is not recommended as a first-line treatment for most types of cough, but may be considered in specific conditions such as cough variant asthma, eosinophilic bronchitis, or severe post-infectious cough that has not responded to other treatments. 1

Types of Cough and Role of Prednisolone

Post-Infectious Cough

• Prednisolone should not be used as first-line therapy for post-infectious cough 1, 2
• First-line treatment should be inhaled ipratropium bromide, which has demonstrated efficacy in controlled trials 1, 2
• For severe paroxysms of post-infectious cough that adversely affect quality of life and persist despite other treatments, consider prednisolone 30-40 mg daily for a short, finite period 1, 2
• This should only be considered after ruling out other common causes of cough such as upper airway cough syndrome, asthma, or GERD 1, 2

Cough Variant Asthma and Eosinophilic Bronchitis

• Prednisolone 30 mg/day for 2 weeks may be used as a diagnostic-therapeutic trial for suspected cough variant asthma or eosinophilic bronchitis 1, 3
• A significant improvement in cough within 3 days of starting prednisolone therapy supports the diagnosis of cough variant asthma 3
• After diagnosis, patients should be transitioned to inhaled corticosteroids for long-term management 1, 3
• If there is no response to prednisolone, alternative diagnoses should be considered 1

Non-Asthmatic Acute Lower Respiratory Tract Infection

• Oral corticosteroids including prednisolone are not effective for acute lower respiratory tract infection in adults without asthma 4
• A randomized clinical trial showed no significant difference in cough duration or symptom severity with prednisolone 40 mg daily for 5 days compared to placebo 4
• Even in patients with unrecognized asthma, prednisolone did not show benefit for acute lower respiratory tract infection 5

Interstitial Lung Disease (ILD)

• For ILD-associated cough, the approach depends on the specific type of ILD 1
• In idiopathic pulmonary fibrosis (IPF), systemic corticosteroids are not recommended due to increased mortality when used in combination therapy 1
• In sarcoidosis, oral corticosteroids may improve symptoms including cough, but require an individualized analysis of benefit and risk 1

Practical Approach to Using Prednisolone for Cough

Diagnostic-Therapeutic Trial Protocol

• For suspected cough variant asthma or eosinophilic bronchitis:
  • Prescribe prednisolone 30 mg daily for 2 weeks 1
  • Assess response within 3 days (significant improvement suggests cough variant asthma) 3
  • If responsive, transition to inhaled corticosteroids for maintenance therapy 1, 3

For Severe Post-Infectious Cough

• Only consider after failure of:
  1. Inhaled ipratropium bromide (first-line) 1, 2
  2. Inhaled corticosteroids (second-line) 1, 2
• Prescribe prednisolone 30-40 mg daily for a short, finite period (2-3 weeks, tapering to zero) 1
• Monitor for improvement and side effects 1

Important Caveats and Pitfalls

• Prednisolone should not be used routinely for non-specific cough or acute lower respiratory tract infection 4, 5
• Long-term systemic corticosteroid use carries significant side effects that must be weighed against potential benefits 1
• The fraction of exhaled nitric oxide (FeNO) measurement may not reliably predict response to anti-inflammatory treatment in chronic cough 6
• Always rule out other common causes of chronic cough (upper airway cough syndrome, GERD) before considering prednisolone 1
• For bronchiectasis, inhaled corticosteroids may be more appropriate than systemic corticosteroids for long-term management 1

Monitoring Response

• Assess improvement in cough frequency, severity, and impact on quality of life 2, 7
• If no response within 2 weeks, reconsider diagnosis and treatment approach 1
• For chronic cough that persists beyond 8 weeks despite treatment, a systematic evaluation for other causes is warranted 2, 7