Oral Steroid Treatment for Adult Acute Asthma Exacerbation
For adults with acute asthma exacerbation, give prednisone 40-60 mg daily as a single dose or in 2 divided doses for 5-10 days without tapering. 1
Dosing Algorithm
Standard Outpatient Management
- Prednisone 40-60 mg daily until peak expiratory flow (PEF) reaches 70% of predicted or personal best 1, 2
- Administer as a single morning dose or split into 2 divided doses 1
- Continue for 5-10 days total 1, 3
- No tapering required for courses less than 7-10 days, especially if patient is on inhaled corticosteroids 1
Severe Exacerbations Requiring Hospitalization
- Prednisone 40-80 mg daily in 1-2 divided doses until PEF reaches 70% of predicted 1, 2
- Alternative: Prednisolone 30-60 mg daily 1, 2
- May require up to 21 days if lung function has not returned to baseline, though 7 days is typically sufficient 1
Route of Administration
Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact 1, 4. A randomized controlled trial of 65 adults demonstrated no difference in PEF improvement between oral prednisolone 100 mg daily versus IV hydrocortisone 100 mg every 6 hours over 72 hours 4.
When to Use IV Steroids
Switch to IV hydrocortisone 200 mg every 6 hours only if: 1, 2
- Patient is vomiting or unable to tolerate oral medications
- Patient is severely ill requiring immediate systemic effect
Critical Timing Considerations
- Administer systemic corticosteroids early in all moderate-to-severe exacerbations 1, 2
- Anti-inflammatory effects take 6-12 hours to become apparent, making early administration crucial 1, 2
- Delaying corticosteroid administration leads to poorer outcomes 1, 2
Duration: Evidence for 5 Days vs 10 Days
A prospective randomized trial comparing 5 versus 10 days of prednisolone 40 mg daily in hospitalized adults found no significant difference in PEF or exacerbation rates when all patients received concurrent inhaled corticosteroids 3. This supports the 5-day minimum duration for outpatient burst therapy 1, though extending to 10 days is reasonable for more severe presentations.
Dose-Response Evidence
While older studies suggested higher doses (0.6 mg/kg or approximately 42 mg for a 70 kg person) showed better response than lower doses 5, more recent evidence demonstrates no additional benefit from doses exceeding 40-80 mg daily 1, 6. A randomized trial comparing hydrocortisone 50 mg, 100 mg, and 500 mg IV every 6 hours found equivalent efficacy across all three doses 6.
Alternative Corticosteroid Options
Equivalent alternatives include: 1
- Prednisolone 40-60 mg daily (same dosing as prednisone)
- Methylprednisolone 60-80 mg daily
- Dexamethasone (various regimens studied, though less commonly recommended)
Common Pitfalls to Avoid
- Do not use arbitrarily short 3-day courses without assessing clinical response—this falls below the evidence-based minimum of 5 days 1
- Do not taper courses lasting less than 7-10 days—tapering is unnecessary and may lead to underdosing during the critical recovery period 1
- Do not use unnecessarily high doses (>80 mg daily)—higher doses increase adverse effects without additional clinical benefit 1, 6
- Do not delay administration—underuse of corticosteroids is associated with increased mortality 2
- Do not prescribe antibiotics unless there is clear evidence of bacterial infection such as pneumonia 2
Monitoring Response
- Measure PEF 15-30 minutes after starting treatment and continue monitoring according to response 1, 2
- Continue treatment until PEF reaches ≥70% of predicted or personal best 1, 2
- Reassess after initial bronchodilator dose and after 60-90 minutes of therapy 1