What is the recommended dosage of prednisone for acute exacerbation of bronchial asthma?

Prednisone Dosage for Acute Asthma Exacerbation

For adults with acute asthma exacerbation, administer prednisone 40-60 mg daily (or prednisolone 30-40 mg daily) for 5-10 days, with oral administration preferred over intravenous unless the patient is vomiting or critically ill. 1, 2

Adult Dosing Recommendations

The optimal dose is 40-80 mg/day of prednisone (or equivalent) until peak expiratory flow reaches 70% of predicted or personal best. 1 More specifically:

• Standard outpatient "burst" therapy: 40-60 mg daily in single or 2 divided doses for 5-10 days 1
• Alternative dosing: prednisolone 30-40 mg daily 2
• Higher doses (120-180 mg/day) offer no additional benefit and should be avoided 1

The evidence strongly supports lower doses. A randomized controlled trial demonstrated that hydrocortisone 50 mg IV four times daily was equally effective as 200 mg or 500 mg doses in resolving acute severe asthma, with no significant differences in FEV1 or peak flow improvement. 3

Pediatric Dosing

For children, administer 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) until peak expiratory flow reaches 70% of predicted or personal best. 1

• Outpatient burst therapy: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1

Route of Administration

Oral administration is strongly preferred and equally effective as intravenous therapy. 4, 1, 2

• A randomized controlled trial of 65 patients found no significant difference in peak flow improvement between oral prednisolone 100 mg once daily versus hydrocortisone 100 mg IV every 6 hours over 72 hours (53.23% vs 55.87% improvement, p=0.28). 5
• Intravenous hydrocortisone 200 mg every 6 hours should be reserved only for patients who are vomiting or critically ill 2
• The National Asthma Education and Prevention Program explicitly states that oral prednisone has effects equivalent to intravenous methylprednisolone but is less invasive 4

Duration and Tapering

Treat for 5-10 days total, with no tapering required for courses under 7-10 days, especially if patients are concurrently taking inhaled corticosteroids. 1, 2

• While 7 days is often sufficient, treatment may need to continue up to 21 days until lung function returns to baseline 2
• Short courses (up to 2 weeks) can be stopped abruptly from full dosage without tapering 2

Timing of Administration

Administer systemic corticosteroids early in the emergency department or outpatient setting for all moderate-to-severe exacerbations and for those not responding to initial bronchodilator therapy. 4, 1

• Corticosteroids should be given to all patients admitted to hospital and considered for community patients with significant breathlessness interfering with daily activities 4
• Early administration is critical because anti-inflammatory effects take 6-12 hours to become apparent 1
• A randomized trial demonstrated that early intervention with prednisone prevented progression in all 22 patients treated, while 8 of 19 placebo patients required rescue intervention (p<0.004) 6

Clinical Pitfalls to Avoid

Do not delay corticosteroid administration - waiting leads to poorer outcomes and higher hospitalization rates. 1

Do not use unnecessarily high doses - doses above 60-80 mg/day provide no additional benefit but increase adverse effects. 1, 3

Do not taper short courses - tapering courses under 7 days is unnecessary and may lead to underdosing during the critical recovery period. 1, 2

Do not use IV route routinely - oral administration is equally effective unless gastrointestinal absorption is impaired. 4, 5

Evidence for Relapse Prevention

A short course of prednisone significantly reduces early relapse rates after emergency department treatment. A randomized controlled trial of 93 patients showed that prednisone (tapered from 40 to 0 mg over 8 days) reduced relapse rates during the first 10 days compared to placebo (3 of 48 vs 11 of 45, p<0.05), with significantly lower symptom scores and less bronchodilator use. 7