Why Give Steroid Medications?
Steroids are given primarily to suppress inflammation in the airways and other tissues, which reduces symptoms, prevents exacerbations, and improves lung function in conditions like asthma and other inflammatory diseases. 1, 2
Primary Mechanisms of Action
Corticosteroids work through multiple anti-inflammatory pathways:
- Suppress airway inflammation by acting on macrophages, eosinophils, lymphocytes, and reducing airway microvascular leak 2
- Reduce bronchial hyperresponsiveness (BHR) by suppressing the allergic inflammatory response in chronic asthma 2
- Decrease mast cell numbers in airways with chronic administration, which reduces immediate responses to allergen and exercise 2
- Inhibit late-phase allergic responses that follow allergen exposure 2
- Produce vasoconstriction, decreased chemotaxis, and interference with macrophages to profoundly affect the inflammatory response 3
Clinical Applications in Respiratory Disease
Acute Asthma Exacerbations
Systemic corticosteroids are cornerstone therapy for asthma exacerbations and significantly reduce hospital admission rates when administered early. 4
- Adults should receive prednisone 40-60 mg daily until peak expiratory flow reaches 70% of predicted or personal best 1
- Children should receive 1-2 mg/kg/day (maximum 60 mg/day) in 2 divided doses until PEF is 70% of predicted 1
- Treatment typically lasts 5-10 days for outpatient management 1
- No tapering is necessary for courses less than 7-10 days, especially if patients are concurrently taking inhaled corticosteroids 1
The anti-inflammatory effects may take 6-12 hours to become apparent, emphasizing the need for early administration. 4
Chronic Asthma Management
Inhaled corticosteroids should be considered first-line therapy for chronic asthma with the aim of suppressing inflammation and reducing the need for bronchodilator therapy. 2
- Patients using short-acting beta-agonists more than 2-3 times per day require maintenance therapy with inhaled corticosteroids 5
- Nocturnal wheezing indicates inadequate control of underlying inflammation 5
- Beclomethasone 400-800 μg/day administered twice daily is an effective starting regimen 5
Other Pulmonary Conditions
Corticosteroids have proven beneficial roles in:
- Croup (laryngotracheobronchitis) 6
- Decreasing risk and severity of respiratory distress syndrome (RDS) 6
- Allergic bronchopulmonary aspergillosis 6
- Interstitial lung disease 6
- Pulmonary eosinophilic disorders 6
Route of Administration Considerations
Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is not impaired. 1, 4
- No advantage exists for IV or IM administration over oral therapy provided GI absorption is intact 1
- Intramuscular steroids should be reserved for patients who are vomiting or unable to tolerate oral medications 1
- Inhaled corticosteroids maximize effective treatment of lung diseases while reducing systemic adverse effects 6
Critical Pitfalls to Avoid
Delaying corticosteroid administration during acute exacerbations worsens outcomes and is associated with increased mortality. 4
- Underuse of corticosteroids is associated with increased mortality in asthma exacerbations 4
- Unnecessarily high doses increase adverse effects without providing additional clinical benefit 1
- Tapering short courses (less than 7 days) is unnecessary and may lead to underdosing during the critical period 1
- Underestimating severity by failing to make objective measurements (PEF, respiratory rate, oxygen saturation) can lead to inadequate treatment 1
Important Safety Considerations
While steroids are highly effective, clinicians must be aware of potential risks:
- Long-term systemic steroids suppress the immune system and increase susceptibility to infections, including reactivation of tuberculosis 7, 8
- Screen for hepatitis B before initiating prolonged treatment, as reactivation can occur 7
- Avoid in presence of systemic fungal infections unless needed to control drug reactions 7
- Monitor for adrenal suppression with prolonged use, which may persist up to 12 months after discontinuation 7
- Inhaled corticosteroids are generally safer with minimal systemic absorption, though not entirely without risk 6, 8
Timing and Monitoring
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. 1