Does an Asthma Control Test (ACT) score of 14, indicating poorly controlled asthma, require oral corticosteroids (e.g. prednisone)?

Does an ACT Score of 14 Require Oral Corticosteroids?

An ACT score of 14 indicates very poorly controlled asthma and warrants consideration of a short course of oral corticosteroids (prednisolone 40-60 mg daily for 3-10 days) to rapidly regain control, particularly if the patient is experiencing frequent symptoms that interrupt sleep or daily activities. 1

Understanding ACT Score of 14

• An ACT score of 14 falls well below the threshold of 20 that indicates well-controlled asthma, placing this patient in the "very poorly controlled" category 1
• This score reflects significant impairment with likely daily symptoms, frequent rescue inhaler use, nighttime awakenings, and interference with normal activities 1
• Very poorly controlled asthma by definition requires stepping up therapy by 1-2 steps and reassessment within 2 weeks 2

When Oral Corticosteroids Are Indicated

A short course of oral systemic corticosteroids should be considered for patients whose asthma frequently interrupts sleep or normal daily activities, or who are experiencing an exacerbation at the time of assessment. 1

• The typical regimen is prednisolone 40-60 mg daily (or 1-2 mg/kg/day, maximum 60 mg/day) as a single dose or divided into 2 doses for 3-10 days 1
• Short courses do not require tapering 2
• This approach helps establish rapid control during periods of gradual deterioration 1

Critical Steps Before Prescribing Oral Steroids

Before initiating oral corticosteroids, you must systematically address potentially reversible factors 1, 2:

• Medication adherence: 40-50% of patients underuse prescribed controller medications due to concerns about side effects 2
• Inhaler technique: At least 50% of patients use inhalers incorrectly, significantly reducing medication effectiveness 3, 2
• Environmental triggers: Identify and address allergens, occupational exposures, and tobacco smoke 2
• Comorbid conditions: Untreated gastroesophageal reflux disease, rhinosinusitis, or use of beta-blockers can make asthma difficult to control 1

Concurrent Controller Therapy Optimization

An ACT score of 14 indicates the patient's current controller regimen is inadequate 1:

• If not already on daily inhaled corticosteroids (ICS), initiate immediately as the fundamental first-line controller therapy 3, 2
• If already on low-dose ICS alone, step up to medium-dose ICS or add a long-acting beta-agonist (LABA) 1
• Consider stepping up 2 steps for very poorly controlled asthma 2

Alternative to Oral Steroids

If the patient has chronic poor control (ACT consistently <20) but is not experiencing an acute exacerbation requiring urgent intervention 1:

• Optimize controller therapy first by stepping up maintenance medications 1
• Schedule close follow-up in 2 weeks to reassess control 2
• Reserve oral corticosteroids for true exacerbations or when rapid control is essential 1

Common Pitfalls to Avoid

• Do not prescribe oral steroids without addressing adherence and technique issues first - this is the most common error leading to repeated courses 3, 2
• Do not use repository injection (methylprednisolone acetate) as first-line - this should only be considered if adherence is a problem or the patient is vomiting 1
• Do not assume the patient understands what "well-controlled" means - patients often accept ongoing symptoms as normal, with 39-70% of patients with moderate symptoms believing their asthma is well controlled 2

Follow-Up Requirements

• Reassess control in 2-6 weeks after initiating or adjusting therapy 1, 2
• Use objective measures including repeat ACT scoring and spirometry or peak flow measurements 1, 2
• Provide a written asthma action plan specifying when to use rescue medications and when to seek urgent care 2
• Consider referral to an asthma specialist if step 4 care or higher is required, or if the patient has had ≥2 exacerbations requiring oral corticosteroids in the past year 1