When is prednisolone (corticosteroid) indicated for acute cough?

Prednisolone for Acute Cough

Prednisolone should NOT be routinely prescribed for acute cough due to acute bronchitis in immunocompetent adults, as high-quality evidence demonstrates no benefit in reducing symptom duration or severity. 1, 2

When Prednisolone is NOT Indicated

Acute Bronchitis (Most Common Scenario)

• Do not prescribe oral corticosteroids for acute bronchitis in immunocompetent adults presenting with acute cough. 1, 3
• A large randomized trial of 398 adults with acute lower respiratory tract infection showed oral prednisolone (40 mg daily for 5 days) did not reduce cough duration (median 5 days in both groups) or symptom severity compared to placebo. 2
• The 2020 CHEST guidelines explicitly recommend against routine prescription of oral corticosteroids for acute bronchitis until treatments are proven safe and effective. 1
• French guidelines state systemic corticosteroids are not justified for acute bronchitis in healthy adults, as the clinical course is spontaneously favorable after approximately 10 days. 3

Important Caveat

• Purulent sputum during acute bronchitis does NOT indicate bacterial superinfection and does not justify corticosteroid treatment. 3
• Even in patients with unrecognized asthma (identified by wheeze and nocturnal symptoms), prednisolone showed no benefit for acute cough (median duration 3 days in both treatment and placebo groups). 4

When Prednisolone IS Indicated

Postinfectious Cough (Subacute Cough: 3-8 Weeks Duration)

For severe paroxysms of postinfectious cough, prescribe prednisolone 30-40 mg daily for a short, finite period ONLY after ruling out other common causes (upper airway cough syndrome, asthma, gastroesophageal reflux disease). 1

Algorithmic approach for postinfectious cough:

1. First-line: Trial of inhaled ipratropium (may attenuate cough). 1
2. Second-line: If cough adversely affects quality of life AND persists despite ipratropium, consider inhaled corticosteroids. 1
3. Third-line: For severe paroxysms only, use oral prednisolone 30-40 mg daily for a short course. 1
4. Last resort: Central antitussives (codeine, dextromethorphan) when other measures fail. 1

Acute Exacerbations of Chronic Bronchitis (NOT Acute Bronchitis)

For acute exacerbations of chronic bronchitis with sudden deterioration (increased sputum volume, purulence, dyspnea), prescribe a short course of systemic corticosteroids (10-15 days). 1, 3

• Recommended dose: Prednisone 40 mg daily for 5-7 days or equivalent. 3
• This improves lung function (FEV₁), oxygenation, and shortens recovery time. 3
• Use oral therapy for ambulatory patients; IV therapy for hospitalized patients. 1

Cough-Variant Asthma

For cough-variant asthma presenting as persistent nonproductive cough, a short diagnostic-therapeutic trial of prednisone can establish diagnosis. 5

• Nine of ten patients in one study reported significant improvement within 3 days of prednisone therapy. 5
• After diagnosis confirmation, transition to inhaled corticosteroids for long-term control. 5

Critical Distinctions to Avoid Common Pitfalls

Acute Bronchitis vs. Acute Exacerbation of Chronic Bronchitis

• Acute bronchitis: New cough in previously healthy person = NO steroids. 1, 2
• Acute exacerbation of chronic bronchitis: Known chronic bronchitis (cough/sputum ≥3 months/year for ≥2 years) with sudden worsening = YES to steroids. 1, 3

Duration-Based Algorithm

• <3 weeks (acute): No prednisolone unless asthma/COPD exacerbation confirmed. 1
• 3-8 weeks (subacute/postinfectious): Consider prednisolone only for severe paroxysms after other treatments fail. 1
• >8 weeks (chronic): Investigate other diagnoses; not postinfectious cough. 1

Key Warnings

• Do not prescribe prednisolone based on wheezing or purulent sputum alone in acute bronchitis—these are not indications for steroid therapy. 3
• Do not use steroids hoping to shorten illness duration in acute bronchitis—evidence shows no benefit. 3, 2
• Mistaking acute bronchitis for asthma exacerbation or pneumonia (which may benefit from steroids) is a common error requiring careful clinical assessment. 3
• If acute bronchitis worsens, reassess for bacterial superinfection or alternative diagnoses (COPD exacerbation, asthma, bronchiectasis) that may require different management including possible corticosteroids. 1