What is the recommended dosing of prednisone (corticosteroid) for an asthma exacerbation?

Prednisone Dosing for Asthma Exacerbation

For adults with asthma exacerbations, the recommended dose of prednisone is 40-80 mg/day until peak expiratory flow reaches 70% of predicted or personal best, with a typical outpatient "burst" dose of 40-60 mg daily for 5-10 days. 1

Adult Dosing Recommendations

• The American College of Allergy, Asthma, and Immunology recommends an initial dose of 40-80 mg/day of prednisone until peak expiratory flow reaches 70% of predicted or personal best 1
• For outpatient "burst" therapy, the recommended dose is 40-60 mg in single or 2 divided doses for a total of 5-10 days 1
• The British Medical Journal recommends a slightly lower dose of 30-40 mg daily for adults 2
• Older guidelines suggested higher doses (120-180 mg/day in 3-4 divided doses for 48 hours, then 60-80 mg/day), but more recent evidence shows no advantage to these higher doses 3, 1

Pediatric Dosing Recommendations

• For children, the recommended dose is 1-2 mg/kg/day (maximum 60 mg/day) in 2 divided doses until peak expiratory flow reaches 70% of predicted or personal best 1, 2
• For outpatient "burst" therapy in children, the same dosing of 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days is recommended 1

Route of Administration

• Oral administration is preferred when patients can tolerate it 1, 2
• No advantage has been found for intravenous administration over oral therapy provided gastrointestinal absorption is not impaired 1, 2
• For patients who are seriously ill or vomiting, intravenous hydrocortisone 200 mg every six hours can be used 2

Duration of Therapy

• The total course of systemic corticosteroids for an asthma exacerbation typically lasts from 3 to 10 days 1, 2
• Treatment should continue until lung function values have returned to previous best, which often takes 7 days but may require up to 21 days in some cases 1, 2
• For corticosteroid courses of less than 1 week, there is no need to taper the dose 1, 2
• For slightly longer courses (up to 10 days), there probably is no need to taper, especially if patients are concurrently taking inhaled corticosteroids 1, 2

Alternative Corticosteroid Options

• Methylprednisolone 60-80 mg/day for 3-10 days is an alternative option for adults 1
• Prednisolone 60 mg/day for 3-10 days can also be used 1
• Single-dose dexamethasone has been studied as an alternative to multi-day prednisone courses, particularly in pediatric patients with mild-to-moderate exacerbations 4

Important Clinical Considerations

• Systemic corticosteroids should be administered early in the treatment of acute exacerbations, as their anti-inflammatory effects may take 6-12 hours to become apparent 1
• Higher doses of corticosteroids have not shown additional benefit in severe asthma exacerbations 1, 5
• Low-dose corticosteroid regimens (such as hydrocortisone 50 mg IV every 6 hours) have been shown to be as effective as higher doses in resolving acute severe asthma 5
• Clinical improvement often precedes resolution of airway inflammation, with symptoms and FEV1 improving within 24 hours while sputum eosinophilia and inflammatory markers may take 48 hours or longer to improve 6

Pitfalls to Avoid

• Delaying administration of systemic corticosteroids during acute exacerbations can lead to poorer outcomes 1
• Unnecessarily high doses of corticosteroids increase the risk of adverse effects without providing additional clinical benefit 1, 5
• Tapering short courses (less than 7 days) of corticosteroids is unnecessary and may lead to underdosing during the critical period 1, 2
• The greatest risk of gastrointestinal bleeding with short-course steroids is in patients with a history of gastrointestinal bleeding or those taking anticoagulants 1