Should oral steroids, such as prednisone, be prescribed to a patient with influenza and a concomitant asthma exacerbation?

Oral Steroids for Influenza with Concomitant Asthma Exacerbation

Oral steroids should be prescribed to a 26-year-old male with influenza and a concomitant asthma exacerbation, as they are essential for treating the inflammatory component of asthma exacerbations and significantly reduce hospital admission rates when administered early. 1

Rationale for Oral Steroid Use

• Systemic corticosteroids are a cornerstone therapy for treating asthma exacerbations, including those triggered by influenza 1
• Underuse of corticosteroids is associated with increased mortality in asthma exacerbations 1
• Steroids should be used in exacerbations of asthma, with oral administration being preferred when patients can tolerate it 2, 3
• When used in short courses of up to two weeks, oral steroids provide important benefits to patients with acute exacerbations of asthma 2

Recommended Dosing Regimen

• For moderate to severe exacerbations, administer oral prednisone 40-60 mg daily until peak expiratory flow reaches 70% of predicted or personal best 1, 3
• For outpatient management, prescribe a "burst" of 40-60 mg in single or divided doses for a total of 5-10 days 1, 3
• When used in short courses of up to two weeks, the dose of oral steroids does not need to be tapered; oral steroids can be stopped from full dosage 2, 3

Route of Administration

• Oral administration is preferred over intravenous when gastrointestinal absorption is not compromised 1, 4
• Studies have shown that corticosteroids administered orally and intravenously have similar efficacy in the treatment of adults hospitalized with acute exacerbation of bronchial asthma 5
• There is no advantage to intravenous administration over oral therapy when gastrointestinal absorption is not impaired 4, 3

Clinical Considerations for Influenza with Asthma Exacerbation

• Consider influenza vaccination for patients with asthma, as they are at risk for complications from influenza 2
• However, the influenza vaccine should not be given with the expectation that it will reduce either the frequency or severity of asthma exacerbations during the influenza season 2
• Early administration of systemic corticosteroids is crucial as their anti-inflammatory effects may not be apparent for 6-12 hours 4

Monitoring and Follow-up

• Measure peak expiratory flow (PEF) 15-30 minutes after starting treatment and then according to response 1
• Monitor for clinical improvement, including reduced work of breathing, decreased respiratory rate, and improved PEF 1
• A one to three month period of stability should be shown before stepwise reduction in maintenance inhaled steroids is undertaken 2

Common Pitfalls to Avoid

• Underestimating the severity of asthma exacerbations, which can lead to inadequate treatment 1
• Delaying corticosteroid administration, which worsens outcomes 1, 4
• Unnecessarily high doses of corticosteroids increase the risk of adverse effects without providing additional clinical benefit 3
• Tapering short courses (less than 7 days) of corticosteroids is unnecessary and may lead to underdosing during the critical period 3

By following these evidence-based recommendations, the 26-year-old male with influenza and concomitant asthma exacerbation can receive appropriate treatment with oral steroids to manage his condition effectively and reduce the risk of complications.