Oral Steroid for Swollen Tonsils in Adult Smoker with URI and Asthma History
For an adult with asthma history presenting with URI symptoms including swollen tonsils, prescribe prednisolone 30-40 mg daily for 7 days (up to 21 days if needed), without tapering if the course is under 2 weeks. 1, 2
Clinical Context and Rationale
This patient presents with two overlapping concerns: URI symptoms (swollen tonsils) and underlying asthma that may be exacerbating. The smoking history increases risk for respiratory complications, making appropriate steroid management critical.
When to Use Oral Steroids
Oral corticosteroids are indicated if this patient shows signs of asthma exacerbation, including: 1, 2
- Day-by-day worsening of symptoms with peak expiratory flow below 60% of patient's best 1, 2
- Sleep disturbance until midday 1, 2
- Diminishing response to inhaled bronchodilators 1, 2
- Requiring short-acting β-agonist more than 2-3 times daily 1
Important caveat: If this is purely pharyngitis/tonsillitis without lower respiratory involvement or asthma exacerbation, oral steroids are not indicated. A 2017 randomized trial of 398 adults with acute lower respiratory tract infection (without asthma) found oral prednisolone provided no benefit for symptom duration or severity compared to placebo. 3
Specific Dosing Protocol
Prednisolone Regimen
- Dose: 30-40 mg daily 1, 2, 4
- Duration: Continue until lung function returns to previous best, typically 7 days but may extend to 21 days 1, 2
- Tapering: Not required for courses up to 2 weeks; can stop abruptly from full dose 1, 2
- Timing: Administer in the morning before 9 AM to minimize adrenal suppression 4
- With food: Take with meals or milk to reduce gastric irritation 4
Alternative if Patient Cannot Tolerate Oral Route
- Intravenous hydrocortisone 200 mg every 6 hours for seriously ill or vomiting patients 2
- However, oral administration is preferred as IV offers no advantages when oral route is feasible 1, 5
Dose Equivalency Evidence
Lower doses are equally effective: A 1992 randomized trial of 66 patients with acute severe asthma found hydrocortisone 50 mg IV four times daily was as effective as 200 mg or 500 mg doses for resolving acute asthma. 6 This supports using the lower end of the recommended 30-40 mg prednisolone range.
Duration flexibility: A 2002 prospective trial comparing 5 versus 10 days of prednisolone 40 mg daily found no significant difference in peak flow outcomes, though this was in hospitalized patients all receiving inhaled corticosteroids. 7 A 2016 Cochrane review found insufficient evidence to determine optimal duration, but current guidelines support 7-21 days based on clinical response. 8
Concurrent Asthma Management
This patient must also receive: 1, 9
- Short-acting β-agonist for acute symptom relief 1, 9
- Inhaled corticosteroids (up to 800 µg/day beclomethasone equivalent) if not already on maintenance therapy 1
- Consider nebulized bronchodilators or large volume spacer device depending on severity 1
Safety Considerations
Gastrointestinal risk: Short courses produce very low rates of GI bleeding; highest risk in patients with prior GI bleeding history or anticoagulant use 1, 2. Consider antacids between meals if giving large doses. 4
Smoking interaction: While smoking status doesn't change the steroid indication or dosing, this patient requires counseling that smoking worsens asthma control and increases exacerbation risk.
Monitoring Requirements
- Measure peak expiratory flow 15-30 minutes after starting treatment 2
- Continue monitoring according to clinical response 2
- Ensure patient has personal asthma action plan 2, 9
- Verify proper inhaler technique 1
What NOT to Do
Do not use intramuscular corticosteroids - these carry risk of serious side effects that may be worse than the condition being treated 1
Do not withhold oral steroids if true asthma exacerbation is present, even in the setting of URI, as the benefits clearly outweigh risks for short-term use 1, 2