Can prednisone be used to treat hyperactive airway disease symptoms, including dry cough, in an adult?

Oral Prednisone for Hyperactive Airway Disease with Dry Cough in Adults

Yes, a 2-week trial of oral prednisolone 30 mg daily is recommended to diagnose and treat corticosteroid-responsive cough in adults with hyperactive airway disease presenting with dry cough. 1

Diagnostic and Therapeutic Approach

Initial Corticosteroid Trial

• A 2-week course of oral prednisolone 30 mg daily serves both diagnostic and therapeutic purposes, as no currently available tests can reliably exclude corticosteroid-responsive cough. 1
• Cough is unlikely to be due to eosinophilic airway inflammation if there is no response to this 2-week oral steroid trial. 1
• This approach is critical because hyperactive airway disease (including cough variant asthma and eosinophilic bronchitis) commonly presents with isolated dry cough without wheezing or dyspnea. 1

Why Oral Steroids Are Appropriate

Hyperactive airway disease encompasses corticosteroid-responsive conditions that frequently manifest as chronic dry cough:

• Cough variant asthma accounts for approximately 30% of chronic cough referrals and responds to corticosteroids even when spirometry is normal. 1
• Eosinophilic bronchitis presents with isolated chronic cough and eosinophilic inflammation without airway hyperresponsiveness, but still responds to corticosteroids. 1
• The presence of non-asthmatic corticosteroid-responsive cough syndromes emphasizes the importance of a trial of corticosteroids in all patients with chronic cough, regardless of airway function test results. 1

Transition to Inhaled Corticosteroids

Once corticosteroid responsiveness is established:

• Inhaled corticosteroids (ICS) become first-line maintenance therapy for long-term control of cough variant asthma and eosinophilic bronchitis. 2
• The American Thoracic Society recommends starting with low to medium doses of ICS (equivalent to beclomethasone 200-800 μg daily) for 4-8 weeks. 2
• If cough persists after initial ICS therapy, increase the dose up to 2000 μg beclomethasone equivalent daily. 2
• Adding a leukotriene receptor antagonist (montelukast) can be considered if response to ICS alone is inadequate. 2

Critical Diagnostic Considerations

Mandatory Initial Workup

Before initiating corticosteroid therapy, ensure:

• Chest radiograph and spirometry are mandatory to exclude other pathology and establish baseline airway function. 1
• Bronchial provocation testing should be performed when available to distinguish cough variant asthma (positive hyperresponsiveness) from eosinophilic bronchitis (negative hyperresponsiveness). 1
• Tests of airway responsiveness are more sensitive and specific than bronchodilator reversibility studies when spirometry is normal or near-normal. 1

Alternative Diagnoses to Consider

A systematic approach must evaluate other common causes of chronic dry cough:

• Gastroesophageal reflux disease (GERD) commonly coexists with or mimics hyperactive airway disease and may require intensive acid suppression with proton pump inhibitors for 3 months. 1, 2
• Upper airway cough syndrome (postnasal drip) is the most common cause of chronic cough in adults and should be treated with first-generation antihistamine/decongestant combinations. 3
• ACE inhibitor use must be excluded, as these drugs commonly cause persistent dry cough. 1
• Smoking cessation should be encouraged, as smoking is one of the commonest causes of persistent cough. 1

Important Caveats and Pitfalls

When NOT to Use Oral Corticosteroids

Oral corticosteroids should NOT be used for acute lower respiratory tract infections in adults without asthma, as they do not reduce symptom duration or severity. 4 This 2017 randomized trial in JAMA found no benefit for cough duration (median 5 days in both groups) or symptom severity in non-asthmatic adults with acute bronchitis. 4

Long-term Steroid Use Concerns

• There is no evidence supporting long-term oral steroid use at doses less than 10-15 mg prednisolone for chronic airway disease. 5
• High-dose oral steroids (≥30 mg prednisolone) improve lung function over short periods but carry risks of diabetes, hypertension, osteoporosis, adrenal suppression, and reduced bone formation. 5
• Transition to inhaled corticosteroids for maintenance therapy minimizes systemic adverse effects while maintaining efficacy. 2

Treatment Monitoring

• Cough control should be expected within 1-2 weeks if due to eosinophilic airway inflammation. 2
• Treatment effects should be formally quantified using cough visual analogue scores or cough-specific quality of life questionnaires. 1
• In patients with apparently corticosteroid-resistant cough, an alternative diagnosis should be considered. 1

Clinical Algorithm Summary

1. Exclude ACE inhibitors and encourage smoking cessation 1
2. Perform chest radiograph and spirometry 1
3. Initiate prednisolone 30 mg daily for 2 weeks as diagnostic/therapeutic trial 1
4. If responsive, transition to inhaled corticosteroids (beclomethasone 200-800 μg daily equivalent) 2
5. If no response after 2 weeks, evaluate for GERD and upper airway cough syndrome 1, 3
6. Consider adding leukotriene receptor antagonist if ICS response inadequate 2