What is the initial dose of steroids to start treatment for asthma?

Initial Steroid Dosing for Asthma Treatment

For asthma treatment, the initial dose of inhaled corticosteroids (ICS) should be based on asthma severity, with low-dose ICS recommended for mild persistent asthma, while systemic corticosteroids (prednisolone 30-60 mg daily for adults or 1-2 mg/kg/day for children) are indicated for acute exacerbations. 1, 2

Inhaled Corticosteroids for Maintenance Therapy

Adults and Children ≥12 Years

• Starting dose is based on asthma severity, typically one inhalation of fluticasone propionate 100/50 (low dose), 250/50 (medium dose), or 500/50 (high dose) twice daily 3
• Low-dose ICS is recommended as first-line controller medication for mild persistent asthma 1
• High-dose ICS provides no additional clinical benefit in most efficacy parameters compared to low or moderate doses for controlling moderate to severe asthma 4

Children 4-11 Years

• One inhalation of fluticasone propionate 100/50 twice daily is the recommended starting dose 3
• Dose should be the lowest effective dose to minimize potential side effects 1, 2

Systemic Corticosteroids for Acute Exacerbations

Adults

• Prednisolone 40-60 mg daily in one or two divided doses until peak expiratory flow (PEF) reaches 70% of predicted or personal best 1
• For outpatient "burst" therapy: 40-60 mg in single or 2 divided doses for 5-10 days 1
• No need to taper the dose for courses less than 1 week 1

Children

• Prednisolone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) until PEF is 70% of predicted or personal best 1
• For outpatient "burst" therapy: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1

Timing and Duration of Treatment

• Early treatment with ICS is beneficial, with greater improvement in lung function observed when treatment is initiated within the first 6 months of symptom onset 1
• For acute exacerbations, systemic corticosteroids should be administered immediately 1
• The total course of systemic corticosteroids for an asthma exacerbation requiring emergency department visit or hospitalization typically lasts 3-10 days 1
• Tapering is not necessary for corticosteroid courses of less than 1 week 1

Important Considerations

• There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations 1
• No advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 1
• Inhaled corticosteroids can be started at any point in the treatment of an asthma exacerbation 1
• Low-dose ICS therapy is generally considered safe, and its benefits outweigh risks for most patients with persistent asthma 1
• Once daily, low-dose budesonide decreases severe asthma-related event risk, reduces lung function decline, and improves symptom control across all symptom frequency subgroups 5

Common Pitfalls to Avoid

• Underestimating the severity of exacerbations, which can lead to inadequate treatment 1, 2
• Delaying administration of systemic corticosteroids during severe exacerbations 2
• Overreliance on bronchodilators without appropriate anti-inflammatory treatment 2
• Using sedatives in asthmatic patients, which is contraindicated and can worsen respiratory depression 6
• Prescribing antibiotics unless bacterial infection is clearly present 6
• Failing to consider potential adverse effects with long-term use of high-dose ICS, including reduced linear growth rate in children or lower bone mineral density in adults 1