Are oral steroids indicated?

Oral Steroids: Not Routinely Indicated Without Specific Diagnosis

Clinicians should not routinely prescribe oral corticosteroids empirically without first establishing a specific diagnosis through appropriate examination and testing. 1

When Oral Steroids Are NOT Indicated

Empiric Use Without Diagnosis

• Do not prescribe oral steroids for dysphonia (hoarseness) prior to visualization of the larynx, as there is an overwhelming lack of supporting data for efficacy and a preponderance of harm over benefit. 1
• Oral steroids should not be used empirically for presumed acute laryngitis despite common practice in primary care and urgent care settings. 1
• Avoid oral steroids for otitis media with effusion (OME) in children, as they do not demonstrate long-term efficacy and carry significant adverse effects including behavioral changes, increased appetite, weight gain, adrenal suppression, fatal varicella infection, and avascular necrosis of the femoral head. 1
• Current guidance recommends avoiding oral steroids for COVID-19-related anosmia due to potential risk of worsening viral infection and increased viral shedding. 1

Significant Adverse Effects

Oral corticosteroids carry substantial risks even with short-term use (<30 days):

• Within 30 days of initiation: 5.3-fold increased risk of sepsis, 3.3-fold increased risk of venous thromboembolism, and 1.9-fold increased risk of fracture. 2
• These risks persist even at prednisone equivalent doses less than 20 mg/day. 2
• Long-term adverse effects (>30% incidence) include sleep disturbances, lipodystrophy, adrenal suppression, metabolic syndrome, weight gain, and hypertension. 1
• Additional serious complications include vertebral fractures (21-30% incidence), acute myocardial infarction, peptic ulcers, cataracts, diabetes, impaired wound healing, and mood disorders. 1

When Oral Steroids ARE Indicated

Asthma Exacerbations (Primary Indication)

For acute asthma exacerbations, oral steroids are strongly indicated and should be administered early:

Adult Dosing Algorithm

• Prednisone 40-60 mg daily (single dose or divided) until peak expiratory flow reaches 70% of predicted or personal best. 3, 4
• For severe exacerbations: 40-80 mg/day in divided doses. 3
• Duration: 5-10 days without tapering for short courses. 3
• No advantage to IV administration over oral therapy when gastrointestinal absorption is intact. 3, 5

Pediatric Dosing Algorithm

• Prednisone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) until peak expiratory flow reaches 70% of predicted. 3
• Duration: 3-10 days without tapering. 3

Critical Timing Considerations

• Administer systemic corticosteroids early in all moderate-to-severe exacerbations, as anti-inflammatory effects take 6-12 hours to become apparent. 3
• Delaying administration leads to poorer outcomes. 3

COPD Exacerbations

• Oral corticosteroids are preferred over intravenous for hospitalized COPD exacerbation patients if gastrointestinal access and function are intact. 1
• Intravenous therapy may increase length of stay and healthcare costs without clear benefit. 1

Bell's Palsy

• Prednisone 50 mg for 10 days OR 60 mg for 5 days with 5-day taper, initiated within 72 hours of symptom onset. 1
• Benefit after 72 hours is less clear. 1

Other FDA-Approved Indications

Oral prednisone is indicated for: endocrine disorders (adrenocortical insufficiency), rheumatic disorders during acute exacerbations, collagen diseases (systemic lupus erythematosus), severe dermatologic diseases, severe allergic states (bronchial asthma, drug hypersensitivity), ophthalmic inflammatory processes, respiratory diseases (symptomatic sarcoidosis), hematologic disorders, neoplastic diseases, edematous states, gastrointestinal diseases (ulcerative colitis), and tuberculous meningitis with appropriate concurrent chemotherapy. 4

Clinical Algorithm for Decision-Making

1. Establish specific diagnosis first through appropriate examination (laryngoscopy for dysphonia, pneumatic otoscopy for OME, spirometry for asthma). 1

2. If asthma exacerbation confirmed:

   • Initiate oral prednisone immediately at appropriate dose
   • Monitor peak expiratory flow at 15-30 minutes and 60-90 minutes
   • Continue until PEF reaches ≥70% predicted
   • No tapering needed for courses <7-10 days

3. If other diagnosis: Consider whether condition is among FDA-approved indications and whether benefits outweigh substantial risks of adverse events. 4, 2

4. Avoid empiric use for undifferentiated symptoms, particularly dysphonia, OME, or viral infections. 1

Common Pitfalls to Avoid

• Do not prescribe oral steroids empirically for respiratory symptoms without establishing diagnosis. 1
• Do not use unnecessarily high doses, as they increase adverse effects without additional benefit. 3
• Do not taper short courses (<7-10 days), as this is unnecessary and may lead to underdosing. 3
• Do not choose IV over oral route without specific indication (vomiting, severe illness), as oral is equally effective and less invasive. 3, 5
• Do not underestimate risks even with short-term use, particularly in patients with history of GI bleeding or on anticoagulants. 2