What is the appropriate dosage and usage of prednisolone (pred) syrup for a cough?

Prednisolone Syrup for Cough: Appropriate Use and Dosing

Prednisolone syrup should NOT be used as first-line treatment for most types of cough, but is reserved for specific conditions: cough-variant asthma, eosinophilic bronchitis, or severe post-infectious cough that has failed other therapies. 1

When to Use Prednisolone for Cough

Cough-Variant Asthma or Eosinophilic Bronchitis

• Use prednisolone 30 mg daily for 2 weeks as a diagnostic-therapeutic trial when spirometry is normal but these conditions are suspected 2
• Expect improvement within 3 days if the diagnosis is correct 3
• After confirming the diagnosis, transition to inhaled corticosteroids for long-term management 2, 4
• If no response occurs within 2 weeks, reconsider the diagnosis 2

Post-Infectious Cough

• First-line treatment is inhaled ipratropium bromide, NOT prednisolone 2, 5
• Consider inhaled corticosteroids if cough persists despite ipratropium and adversely affects quality of life 2, 5
• For severe paroxysms only: prescribe prednisolone 30-40 mg daily for a short, finite period after other treatments have failed 2, 5
• This should only be used after ruling out upper airway cough syndrome, asthma, and gastroesophageal reflux disease 2, 5

Acute Lower Respiratory Tract Infection (Bronchitis)

• Do NOT use prednisolone for acute bronchitis in adults without asthma 6
• A high-quality 2017 randomized controlled trial demonstrated that prednisolone 40 mg daily for 5 days did not reduce cough duration or symptom severity compared to placebo 6

Dosing Specifics

Adults

• Diagnostic-therapeutic trial: 30 mg daily for 2 weeks 2, 3
• Severe post-infectious cough: 30-40 mg daily for a short period (typically 2-3 weeks with taper) 2
• FDA-approved dosing range: 5-60 mg per day depending on condition severity 7

Pediatric Patients

• Initial dosing range: 0.14-2 mg/kg/day in 3-4 divided doses 7
• For asthma uncontrolled by inhaled corticosteroids: 1-2 mg/kg/day in single or divided doses 7
• Short "burst" therapy: continue until peak flow reaches 80% of personal best or symptoms resolve (usually 3-10 days) 7
• No evidence supports tapering after improvement to prevent relapse 7

Critical Pitfalls to Avoid

• Never use prednisolone as first-line for post-infectious cough—start with inhaled ipratropium 2, 5
• Do not use antibiotics for post-infectious viral cough—they have no role unless bacterial infection is confirmed 2, 5
• Do not use prednisolone for acute bronchitis in non-asthmatics—it is ineffective and exposes patients to unnecessary side effects 6
• Always perform spirometry before considering prednisolone for chronic cough to identify airflow obstruction 2
• If cough persists beyond 8 weeks, reclassify as chronic cough and evaluate for other causes (gastroesophageal reflux, upper airway cough syndrome) 2, 5
• Long-term systemic corticosteroids carry significant side effects—transition to inhaled corticosteroids as soon as diagnosis is confirmed 2, 1, 4

Algorithmic Approach

1. Determine cough duration: Acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) 5
2. Perform chest radiograph and spirometry for chronic cough 2
3. For post-infectious cough: Start inhaled ipratropium → add inhaled corticosteroids if needed → consider oral prednisolone only for severe cases 2, 5
4. For suspected cough-variant asthma/eosinophilic bronchitis with normal spirometry: Trial prednisolone 30 mg daily for 2 weeks 2, 3
5. If response occurs within 3 days: Confirm diagnosis and switch to inhaled corticosteroids 3, 4
6. If no response after 2 weeks: Stop prednisolone and investigate alternative diagnoses 2