What is the recommended dose of prednisolone (corticosteroid) for a cough?

Prednisolone Dosing for Cough

For chronic cough suspected to be due to cough variant asthma or eosinophilic bronchitis, use prednisolone 30 mg daily for 2 weeks as a diagnostic-therapeutic trial. 1, 2

Diagnostic-Therapeutic Trial Approach

The recommended approach uses prednisolone as both a diagnostic test and treatment for steroid-responsive cough syndromes:

• Dose: 30 mg prednisolone orally once daily 1, 2
• Duration: 2 weeks 1, 2
• Interpretation: Cough is unlikely to be due to eosinophilic airway inflammation if there is no response to this regimen 1
• Assessment timing: Evaluate response within 3 days, though the full trial should continue for 2 weeks 2

This guideline-based recommendation comes from expert consensus in the Thorax guidelines, which specifically state that "expert opinion is that cough is unlikely to be due to eosinophilic airway inflammation if there is no response to treatment with prednisolone 30 mg/day for 2 weeks." 1

When to Consider Prednisolone for Cough

Prednisolone should NOT be first-line treatment for most cough types. 2 Consider it only in these specific scenarios:

• Suspected cough variant asthma: When spirometry is normal or near-normal but clinical indicators suggest asthma (nocturnal cough, post-exercise cough, allergen exposure-related cough) 1, 2
• Suspected eosinophilic bronchitis: Chronic cough with normal spirometry, no airway hyperresponsiveness, but suspected eosinophilic inflammation 1, 2
• Severe post-infectious cough: Only after failure of first-line treatment with inhaled ipratropium bromide, use 30-40 mg daily for a short, finite period 2, 3

Transition to Long-Term Management

After confirming steroid-responsive cough, transition immediately to inhaled corticosteroids rather than continuing oral prednisolone. 1, 2

• Inhaled corticosteroids are the appropriate long-term treatment for cough variant asthma and eosinophilic bronchitis 1
• Long-term oral corticosteroids should NOT be used for stable chronic cough due to significant adverse effects without proven benefit 1, 4
• For severe or refractory asthmatic cough, a short course (1-2 weeks) of oral corticosteroids followed by inhaled corticosteroids is recommended 1

Important Caveats and Pitfalls

Do not use prednisolone for these cough types:

• Acute lower respiratory tract infection in non-asthmatics: A high-quality 2017 randomized trial showed 20 mg prednisolone daily for 5 days provided no benefit for cough duration or severity 5
• Stable COPD: Long-term oral corticosteroids (doses <10-15 mg prednisolone) show no evidence of benefit and carry significant risks including diabetes, hypertension, and osteoporosis 1, 4
• First-line treatment for any cough: Always rule out common causes and try appropriate first-line therapies before considering systemic corticosteroids 2

For COPD exacerbations specifically:

• Use 30-40 mg prednisolone daily for 5 days (not 2 weeks) 1, 6
• A landmark 2013 REDUCE trial demonstrated that 5 days of 40 mg prednisone was non-inferior to 14 days for COPD exacerbations while significantly reducing steroid exposure 6
• This applies to acute exacerbations, not chronic cough management 1, 6

Monitoring Response

Assess these parameters to determine treatment success:

• Cough frequency and severity reduction 2
• Impact on quality of life 2
• If no response within 2 weeks, reconsider the diagnosis and explore alternative causes 1, 2
• In patients with apparently corticosteroid-resistant cough variant asthma, an alternative diagnosis should be considered 1

Always exclude other common causes of chronic cough before attributing response to steroid-responsive airway disease: 2

• Gastroesophageal reflux disease 1
• Upper airway cough syndrome (postnasal drip) 1
• Medication-induced cough (ACE inhibitors) 1
• Bronchiectasis 1