What is the recommended systemic steroid treatment for severe asthma exacerbations in adults?

Systemic Steroid Treatment for Severe Asthma Exacerbations in Adults

For severe asthma exacerbations in adults, oral prednisone 40-60 mg daily (or equivalent) should be administered until peak expiratory flow reaches 70% of predicted or personal best, typically for 5-10 days. 1

Initial Assessment and Classification

• Severe asthma exacerbation is characterized by: inability to complete sentences in one breath, respiratory rate >25 breaths/min, PEF <50% of predicted/best, and heart rate >110 beats/min 1
• Life-threatening features include: PEF <33% of predicted/best, silent chest, cyanosis, feeble respiratory effort, bradycardia/hypotension, exhaustion, confusion, or coma 1
• Arterial blood gas tensions should be measured in severe cases, with normal/high PaCO₂, severe hypoxia (PaO₂ <8 kPa), or low pH indicating life-threatening status 1

Systemic Corticosteroid Regimen

Recommended Dosing

• Oral prednisone 40-80 mg daily until PEF reaches 70% of predicted or personal best 1
• Alternative: IV hydrocortisone 200 mg every 6 hours for patients who are seriously ill or vomiting 1
• For outpatient management, a "burst" of 40-60 mg in single or divided doses for a total of 5-10 days 1

Route of Administration

• Oral administration is preferred when gastrointestinal absorption is not compromised 1, 2
• No proven advantage for IV administration over oral therapy when GI transit time or absorption is normal 1, 2
• IV route may be preferable in patients with severe asthma where absorption might be compromised 2

Duration of Treatment

• Total course typically lasts 5-10 days 1
• For courses less than 1 week, there is no need to taper the dose 1
• For courses up to 10 days, tapering is probably unnecessary, especially if patients are concurrently taking inhaled corticosteroids 1

Special Considerations

• Systemic corticosteroids should be administered early in the treatment course, as their anti-inflammatory effects may take 6-12 hours to appear 2
• Underuse of corticosteroids is associated with increased mortality in asthma 2
• Morning administration (before 9 am) may help reduce adrenal suppression 3
• Gastric irritation may be reduced if taken with food or milk 3

Evidence on Dosing Variations

• Research comparing low-dose hydrocortisone (50 mg IV q6h) with higher doses (100 mg or 500 mg q6h) found no significant difference in effectiveness for resolving acute severe asthma 4
• A study comparing 5 vs. 10 days of oral prednisolone (40 mg daily) found no significant difference in morning PEF or exacerbation rates, suggesting a 5-day course may be sufficient when patients receive inhaled corticosteroids and have an asthma management plan 5
• A single intramuscular dose of triamcinolone diacetate (40 mg) produced similar relapse rates to a 5-day course of oral prednisone (40 mg daily) and may be an option when compliance is a concern 6

Common Pitfalls to Avoid

• Underestimating the severity of asthma exacerbations, which can lead to inadequate treatment and potentially fatal outcomes 1, 2
• Delaying corticosteroid administration, which can lead to poorer outcomes 2
• Using sedatives, which are contraindicated in asthma exacerbations 1
• Prescribing antibiotics unless there is clear evidence of bacterial infection (e.g., pneumonia or sinusitis) 1
• Failing to monitor response to treatment with objective measurements such as PEF 1

Monitoring and Follow-up

• Measure PEF 15-30 minutes after starting treatment and then according to response 1
• Continue oxygen therapy to maintain SaO₂ >90% (>95% in pregnant women and patients with heart disease) 1
• If condition improves, give nebulized β-agonist every four hours 1
• If condition does not improve after 15-30 minutes, give nebulized β-agonists more frequently (up to every 15 minutes) 1
• Consider adding ipratropium bromide to β-agonist therapy to increase bronchodilation in severe cases 1