Systemic Steroids in Adult Asthma Management
Systemic corticosteroids play a crucial role in adult asthma management, particularly for treating acute exacerbations, with oral prednisone 40-60 mg daily for 5-10 days being the recommended regimen for severe episodes. 1
Role in Acute Exacerbations
- Systemic corticosteroids (usually oral tablets for adults, but also including intravenous or intramuscular preparations) are a mandatory component in the treatment of severe asthma exacerbations 2
- For outpatient management of exacerbations, a "burst" of prednisone 40-60 mg in single or divided doses for a total of 5-10 days is recommended 1
- For patients who are seriously ill or vomiting, IV hydrocortisone 200 mg every 6 hours is an appropriate alternative 1
- Systemic corticosteroids should be administered early in the treatment course, as their anti-inflammatory effects may take 6-12 hours to appear 1
Dosing Considerations
- Short courses of oral systemic corticosteroids are effective for resolving acute asthma symptoms and exacerbations 3
- For severe exacerbations requiring hospitalization, oral prednisone should be continued until peak expiratory flow (PEF) reaches 70% of predicted or personal best 1
- The American Thoracic Society/European Respiratory Society defines a severe exacerbation as requiring systemic corticosteroids for at least 3 days 2
- A 2-day course of oral dexamethasone (16 mg daily) has been shown to be at least as effective as a 5-day course of oral prednisone (50 mg daily) in returning patients to their normal level of activity and preventing relapse 4
Long-term Use in Severe Asthma
- Oral systemic corticosteroids are used long-term only for patients with severe persistent asthma (step 6 care) when other treatments have failed 2
- In a small minority of patients with severe asthma, corticosteroid tablets may be needed on a regular basis for day-to-day treatment 2
- Regular corticosteroid tablet usage reflects asthma severity ("difficult to treat" asthma), whereas the frequency of courses needed is a marker of control 2
Safety Considerations
- Even short courses (3-7 days) of systemic corticosteroids can cause significant adverse effects 3
- Short-term use may cause reversible abnormalities in glucose metabolism, increased appetite, fluid retention, weight gain, mood alteration, and hypertension 2
- Long-term use can lead to adrenal axis suppression, growth suppression, dermal thinning, hypertension, diabetes, Cushing syndrome, cataracts, muscle weakness, and rarely impaired immune function 2
- Patients should be monitored for cumulative systemic corticosteroid exposure, with 1 gram per year proposed as a relevant threshold for increased risk of adverse effects 3
Common Pitfalls to Avoid
- Underestimating the severity of asthma exacerbations, which can lead to inadequate treatment and potentially fatal outcomes 1
- Delaying corticosteroid administration during acute exacerbations 1
- 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
- Underuse of corticosteroids during severe exacerbations is associated with increased mortality 1
Alternatives and Strategies to Reduce Systemic Steroid Use
- Inhaled corticosteroids (ICS) are the most consistently effective long-term control medication for persistent asthma 2
- For mild persistent asthma, low-dose daily ICS is generally sufficient without requiring systemic steroids 5
- For moderate persistent asthma, the combination of an ICS and long-acting beta-agonist (LABA) is preferred over increasing ICS doses 5
- Biomarker-directed treatment approaches (targeting type-2 inflammation) may help reduce the need for systemic corticosteroids in some patients 2
- Strategies to reduce systemic corticosteroid use include improving adherence to controller medications, proper inhaler technique, and appropriate use of add-on therapies including biologics in eligible patients 3
In conclusion, while systemic corticosteroids are essential for managing acute asthma exacerbations, their use should be limited to short courses whenever possible due to potential adverse effects. The goal of long-term asthma management should be to achieve control with inhaled medications and minimize the need for systemic steroids.