Burst Steroid Dosing for a 5-Day Course
For adults, prescribe prednisone 40-60 mg daily for 5 days without tapering; for children, prescribe 1-2 mg/kg/day (maximum 60 mg/day) for 5 days without tapering. 1, 2
Adult Dosing
- Prednisone 40-60 mg daily as a single dose or in 2 divided doses for 5-10 days is the standard outpatient burst regimen 1, 2
- The dose can be given as a single morning dose (preferred) or split into 2 divided doses throughout the day 1
- For severe exacerbations requiring hospitalization, 40-80 mg/day in divided doses until peak expiratory flow reaches 70% of predicted or personal best may be used 1
- No tapering is necessary for courses lasting 5-10 days, especially if the patient is concurrently taking inhaled corticosteroids 1, 2
Pediatric Dosing
- Prednisone 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days is the recommended pediatric burst dose 1, 2
- The dose should be given in 2 divided doses for optimal effect 1
- The maximum daily dose is 60 mg regardless of weight 1
- No tapering is required for short courses of 5-10 days 1, 2
Route of Administration
- Oral administration is strongly preferred and equally effective as intravenous therapy 1, 2
- There is no advantage to intravenous administration over oral therapy provided gastrointestinal absorption is not impaired 1, 2
- Administer in the morning (prior to 9 AM) to minimize adrenal suppression, as this aligns with the body's natural cortisol peak 3
- Take with food or milk to reduce gastric irritation 3
Duration Considerations
- The typical outpatient burst course lasts 5-10 days 1, 2
- Five days is sufficient for most acute exacerbations and is supported by high-quality evidence 2, 4
- Courses longer than 5-7 days provide no additional benefit and increase side effect risk 2, 4
- Treatment should continue until clinical control is established, not for an arbitrary fixed period 2
Important Clinical Pitfalls to Avoid
- Do not taper doses for courses lasting less than 7-10 days - tapering is unnecessary and may lead to underdosing during the critical recovery period 1, 2
- Do not use unnecessarily high doses - higher doses of corticosteroids have not shown additional benefit in severe exacerbations 1, 2
- Do not delay administration - systemic corticosteroids should be started early in acute exacerbations, as their anti-inflammatory effects take 6-12 hours to become apparent 2
- Avoid using arbitrarily short courses (like 3 days) without assessing clinical response, as this may result in treatment failure 2
Alternative Corticosteroid Options
- Prednisolone 40-60 mg/day for adults or 1-2 mg/kg/day (maximum 60 mg/day) for children can be substituted at equivalent doses 1, 2
- Methylprednisolone 60-80 mg/day for adults or 0.25-2 mg/kg/day for children is another alternative 1, 2
- All oral corticosteroids are equally effective when given at equivalent doses 1, 2
Evidence Quality Note
The 5-day regimen at these doses is supported by the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines and represents the standard of care for outpatient burst therapy 1. Research confirms that HPA axis function returns to normal within 1 week after discontinuation of short burst therapy 5, and early relapse rates are significantly reduced with this approach 6.