What is the recommended dose and duration of systemic steroids, such as prednisone, for adult asthma patients experiencing a severe exacerbation?

Systemic Steroid Treatment for Severe Asthma Exacerbations in Adults

For adult patients experiencing severe asthma exacerbations, oral prednisone should be administered at a dose of 40-60 mg daily for 5-10 days without tapering. 1, 2

Dosing Recommendations

• Oral prednisone 40-60 mg daily in a single dose or divided doses should be continued until peak expiratory flow (PEF) reaches 70% of predicted or personal best 1, 2
• For most outpatient exacerbations, a 5-10 day course is sufficient, with no need to taper the dose for courses of this duration 1
• Alternative option: If the patient is unable to take oral medications (e.g., vomiting or seriously ill), intravenous hydrocortisone 200 mg every 6 hours can be administered 1, 2
• For hospitalized patients, prednisolone 30-40 mg daily should be given until lung function returns to previous best values 1

Duration of Treatment

• Though 5-10 days is typically sufficient for most patients, treatment may need to be continued for up to 21 days in some cases of severe exacerbations 1, 2
• Research comparing 5 vs. 10 days of prednisolone (40 mg daily) showed no significant difference in morning peak expiratory flow or exacerbation rates, suggesting that shorter courses may be adequate when patients are also receiving inhaled corticosteroids 3
• There is no need to taper the dose for corticosteroid courses of less than 1 week, and probably no need to taper for courses up to 10 days, especially if patients are concurrently taking inhaled corticosteroids 1

Route of Administration

• Oral administration is preferred and equally effective as intravenous administration, provided gastrointestinal transit time or absorption is not impaired 1
• Intravenous administration offers no advantages over oral administration for most patients 1

Monitoring Response

• Measure PEF 15-30 minutes after starting treatment and thereafter according to response 1, 2
• Clinical improvement and blood markers typically improve within 24 hours of starting treatment, while sputum inflammatory markers may take up to 48 hours to show improvement 4
• Continue oxygen therapy to maintain oxygen saturation >90% (>95% in pregnant women and patients with cardiac disease) 2

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 worsen outcomes as their anti-inflammatory effects may take 6-12 hours to appear 2
• Using lower doses than recommended - research has shown a dose-response relationship with better outcomes at higher doses (minimum 0.6 mg/kg of prednisolone) 5
• Prescribing antibiotics unless there is clear evidence of bacterial infection 2

Special Considerations

• For patients with a history of gastrointestinal bleeding or those taking anticoagulants, monitor closely as they have a higher risk of steroid-induced gastrointestinal bleeding 1
• Consider adding ipratropium bromide to β-agonist therapy to increase bronchodilation in severe cases 2
• Inhaled corticosteroids can be started at any point during the treatment of an asthma exacerbation 1

While some older studies suggested that lower doses of corticosteroids might be effective 6, more recent guidelines consistently recommend the 40-60 mg dose range for optimal management of severe exacerbations 1, 2.