Prednisone Dosing for Asthma Exacerbation
For adults with asthma exacerbations, prescribe prednisone 40-60 mg daily as a single dose or in 2 divided doses for 5-10 days without tapering; for children, prescribe 1-2 mg/kg/day (maximum 60 mg/day) in 2 divided doses for 3-10 days without tapering. 1
Adult Dosing Algorithm
Initial dosing: Start prednisone 40-60 mg daily until peak expiratory flow (PEF) reaches 70% of predicted or personal best 2, 1. For severe exacerbations requiring hospitalization, you may use 40-80 mg/day in divided doses until the same PEF target is achieved 1.
Duration: Continue treatment for 5-10 days total 2, 1. The standard outpatient "burst" regimen is 40-60 mg in single or 2 divided doses for this duration 1. While 7 days is often sufficient, treatment may need to extend up to 21 days if lung function has not returned to the patient's previous baseline 1.
No tapering required: For courses lasting less than 7-10 days, do not taper the dose—this is unnecessary and may lead to underdosing during the critical recovery period, especially if patients are concurrently taking inhaled corticosteroids 2, 1.
Pediatric Dosing Algorithm
Initial dosing: Prescribe prednisone 1-2 mg/kg/day in 2 divided doses with a maximum of 60 mg/day, regardless of weight 2, 1. Continue until PEF reaches 70% of predicted or personal best 2.
Duration: Treat for 3-10 days 2, 1. The typical outpatient burst course is 5-10 days 1.
No tapering required: Short courses of 5-10 days do not require tapering 1.
Route of Administration
Oral is strongly preferred: There is no advantage to intravenous administration over oral therapy when gastrointestinal absorption is intact 2, 1. Oral prednisone has effects equivalent to intravenous methylprednisolone but is less invasive 1.
When to use IV: Reserve intravenous hydrocortisone 200 mg every 6 hours for patients who are vomiting, severely ill, or unable to tolerate oral medications 1, 3.
Timing and Clinical Considerations
Administer early: Give 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. The anti-inflammatory effects take 6-12 hours to become apparent, so delays worsen outcomes 1.
Monitor response: Measure PEF 15-30 minutes after starting treatment and continue monitoring according to response 1. Clinical improvement typically includes reduced work of breathing, decreased respiratory rate, and improved PEF 3.
Continue treatment until control: Treatment should continue until two days after control is established, not for an arbitrary 3-day period 1. The evidence-based minimum is 5-10 days for outpatient management 1.
Important Clinical Pitfalls to Avoid
Don't use unnecessarily high doses: Higher doses of corticosteroids (beyond 60-80 mg/day) have not shown additional benefit in severe asthma exacerbations and only increase adverse effects 2, 1. Research demonstrates that hydrocortisone 50 mg IV four times daily is as effective as 200 mg or 500 mg doses 4.
Don't use arbitrarily short courses: Using 3-day courses without assessing clinical response may result in treatment failure 1. The evidence supports a minimum of 5 days 1.
Don't delay administration: Underuse of corticosteroids is associated with increased mortality in asthma exacerbations 3. Delaying corticosteroid administration worsens outcomes 1.
Don't taper short courses: Tapering courses less than 7-10 days is unnecessary and may lead to underdosing during the critical recovery period 2, 1.
Alternative Corticosteroid Options
If prednisone is unavailable, equivalent alternatives include 1:
- Prednisolone: 40-60 mg/day for adults or 1-2 mg/kg/day (maximum 60 mg/day) for children
- Methylprednisolone: 60-80 mg/day for adults or 0.25-2 mg/kg/day for children
- IV hydrocortisone: 200 mg every 6 hours for severely ill patients
All oral corticosteroids are equally effective when given at equivalent doses 1.
Concurrent Therapy
Ensure patients continue inhaled corticosteroids at appropriate doses and receive frequent inhaled short-acting beta-agonists (SABA) 1, 3. Consider adding ipratropium bromide 0.5 mg to beta-agonist treatments, particularly in severe exacerbations 1.