Oral Steroids for Dry Cough: Dosing Recommendations
For severe post-infectious dry cough that has failed first-line therapy, prescribe prednisolone 30-40 mg daily for a short, finite period (typically 2-3 weeks with tapering). 1, 2, 3
Clinical Context and Indications
Oral corticosteroids are not first-line therapy for dry cough and should only be considered in specific circumstances after other treatments have failed. 2, 3
When to Consider Oral Steroids
Post-infectious cough (3-8 weeks duration):
- Only after inhaled ipratropium bromide has failed 1, 2
- Only after inhaled corticosteroids have been tried 1, 2
- Only when cough severely impacts quality of life with paroxysmal episodes 1, 3
- Must rule out upper airway cough syndrome, asthma, and GERD first 1, 2
Cough variant asthma (diagnostic-therapeutic trial):
- Prednisolone 30 mg daily for 2 weeks as both diagnostic test and initial treatment 3, 4
- Expect response within 1-2 weeks if asthma is the cause 4
- Transition to inhaled corticosteroids for long-term management after diagnosis confirmed 3, 4
Specific Dosing Regimens
Post-Infectious Cough
- Dose: Prednisolone 30-40 mg orally once daily in the morning 1, 2, 3
- Duration: Short, finite period (typically starting dose for 2-3 weeks, then taper to zero over 2-3 weeks total) 1
- Route: Oral administration 1
Cough Variant Asthma (Diagnostic Trial)
- Dose: Prednisolone 30 mg daily 3, 4
- Duration: 2 weeks 3, 4
- Assessment: Evaluate response within 3 days to 1-2 weeks 3, 4
Acute Exacerbation of Chronic Bronchitis
- Dose: Not specifically defined in guidelines, but 10-15 day course recommended 1
- Context: For ambulatory patients (IV therapy reserved for hospitalized patients) 1
Treatment Algorithm
First-line: Inhaled ipratropium bromide (demonstrated efficacy in controlled trials) 1, 2, 5
Second-line: Inhaled corticosteroids when cough persists despite ipratropium and adversely affects quality of life 1, 2
Third-line: Oral prednisolone 30-40 mg daily only for severe paroxysms after ruling out UACS, asthma, and GERD 1, 2, 3
Last resort: Central-acting antitussives (codeine, dextromethorphan) when all other treatments fail 2
Critical Pitfalls to Avoid
Do not use antibiotics for post-infectious cough unless bacterial sinusitis or pertussis is confirmed—bacterial infection does not play a role in typical post-infectious cough. 1, 2, 5
Do not use oral steroids as first-line therapy for acute lower respiratory tract infection in adults without asthma—a 2017 randomized trial showed no benefit for symptom duration or severity. 6
Reclassify as chronic cough if symptoms persist beyond 8 weeks and initiate systematic evaluation for other causes rather than continuing steroid therapy. 1, 2, 5
Avoid long-term oral steroid use at any dose for stable chronic cough—there is no evidence of benefit and significant risk of adverse effects including hyperglycemia, adrenal suppression, and reduced bone density. 1, 7
Monitoring Adverse Effects
Short-term risks (even with brief courses):
- Reversible glucose metabolism abnormalities 1
- Increased appetite and fluid retention 1
- Facial flushing and mood alterations 1
- Hypertension 1
- Peptic ulcer disease 1
Assess coexisting conditions that could be worsened by systemic corticosteroids before prescribing. 1
Special Populations
Children (<5 years):
- Methylprednisolone/prednisolone/prednisone: 1-2 mg/kg/day, maximum 60 mg/day for 3-10 days 1
Adults and children ≥5 years:
- 40-60 mg/day as single or 2 divided doses for 3-10 days 1