Prednisone Dosing for Asthma Exacerbations
For adults with asthma exacerbations, use prednisone 40-60 mg daily for 5-10 days without tapering; for children, use 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days without tapering. 1
Adult Dosing Algorithm
Outpatient "burst" therapy:
- Prednisone 40-60 mg daily as a single morning dose or in 2 divided doses 2, 1
- Continue until peak expiratory flow (PEF) reaches 70% of predicted or personal best 2, 1
- Standard duration: 5-10 days 2, 1
- No tapering required for courses ≤10 days, especially if patient is on inhaled corticosteroids 2, 1
Severe exacerbations requiring hospitalization:
- Prednisone 40-80 mg/day in divided doses until PEF reaches 70% of predicted or personal best 2, 1
- May require 7-21 days if lung function has not returned to baseline 1
Pediatric Dosing Algorithm
Standard regimen:
- Prednisone 1-2 mg/kg/day in 2 divided doses 2, 1
- Maximum 60 mg/day regardless of weight 2, 1
- Duration: 3-10 days 2, 1
- Continue until PEF reaches 70% of predicted or personal best 2, 1
- No tapering required for short courses 2, 1
Route of Administration
Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact 2, 1. There is no advantage to IV administration over oral therapy provided GI transit time is not impaired 2, 1.
Reserve IV/IM steroids only for:
- Patients who are vomiting 1
- Severely ill patients unable to tolerate oral medications 1
- If IV route necessary: hydrocortisone 200 mg every 6 hours 1
Critical Timing Considerations
Administer systemic corticosteroids early in all moderate-to-severe exacerbations and in those not responding to initial bronchodilator therapy 1. The anti-inflammatory effects may take 6-12 hours to become apparent, making early administration crucial 1, 3.
Duration and Tapering Guidelines
- 5-10 days is the evidence-based standard for outpatient management 2, 1
- No tapering necessary for courses <7-10 days, especially with concurrent inhaled corticosteroids 2, 1
- For hospitalized patients, continue until 2 days after control is established 2, 1
- Some severe cases may require up to 21 days until lung function returns to baseline 1
Alternative Corticosteroid Options
All oral corticosteroids are equally effective at equivalent doses 1:
- Prednisolone: Same dosing as prednisone 1
- Methylprednisolone: 60-80 mg/day for adults 1
- Dexamethasone: 16 mg daily for 2 days (alternative shorter course) 4
Evidence Quality Note
The 5-day minimum duration is supported by high-quality randomized trial evidence showing equivalence to 10-day courses when patients receive concurrent inhaled corticosteroids 1, 5. A study comparing 5 vs 10 days of prednisolone 40 mg daily found no significant difference in PEF or relapse rates 5.
Critical Pitfalls to Avoid
Do not use arbitrarily short courses (e.g., 3 days) without assessing clinical response, as this may result in treatment failure 1. The 3-day duration is shorter than the evidence-based minimum of 5-10 days 1.
Do not delay administration during acute exacerbations, as this leads to poorer outcomes and is associated with increased mortality 1, 3.
Do not use unnecessarily high doses, as higher doses have not shown additional benefit in severe exacerbations but increase adverse effect risk 2, 1.
Do not taper short courses, as tapering is unnecessary and may lead to underdosing during the critical recovery period 2, 1.
Do not underestimate severity by failing to make objective measurements (PEF, respiratory rate, oxygen saturation) 1.