Is prednisone effective for treating wheezing?

Prednisone for Wheezing: Evidence-Based Recommendation

For acute asthma exacerbations with wheezing in adults and older children, prednisone (40-60 mg daily for 5-7 days) is highly effective and should be used when symptoms are severe or incompletely responsive to bronchodilators. 1 However, for preschool children with virus-induced wheezing, oral corticosteroids including prednisone are generally not effective and should not be routinely used. 2

Adult and Older Children with Asthma-Related Wheezing

When to Use Prednisone

Prednisone is indicated for:

• Acute severe asthma with wheezing, respiratory rate >25/min, heart rate >110/min, or peak expiratory flow <50% predicted 1
• Asthmatic cough or wheezing that is severe or only partially responsive to inhaled corticosteroids and bronchodilators 1
• Patients requiring emergency department care or hospitalization for acute exacerbations 1, 3

Dosing and Duration

• Adults: Prednisolone 30-60 mg daily for 5-7 days, or prednisone 40 mg daily for 1 week 1
• Children with confirmed asthma: Prednisone 1-2 mg/kg/day (maximum 40-60 mg) for 5-7 days 1
• No tapering is necessary for short courses (≤7 days) 1

Evidence Supporting Use

Early intervention with oral prednisone in ambulatory patients with acute asthma exacerbations incompletely responsive to bronchodilators prevents progression requiring emergency care—all 22 patients receiving prednisone improved versus 8 of 19 placebo patients requiring rescue intervention (p<0.004). 3 The British Thoracic Society guidelines emphasize immediate administration of systemic steroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg) for acute severe asthma. 1

Preschool Children with Virus-Induced Wheezing

Strong Evidence Against Routine Use

Oral prednisolone should NOT be routinely used for preschool children (10 months to 6 years) presenting with acute virus-induced wheezing. 2

The highest quality evidence comes from a large randomized, double-blind, placebo-controlled trial of 687 preschool children with viral wheezing: prednisolone showed no benefit over placebo for duration of hospitalization (11.0 vs 13.9 hours, p=NS), symptom scores, albuterol use, or any secondary outcomes. 2

Exceptions and Nuances

Prednisolone may have limited benefit in:

• First-time wheezers with high rhinovirus load (>7000 copies/mL) and severe episodes—one study showed reduced risk of requiring asthma control medication at 4-year follow-up (p=0.05 for interaction) 4
• However, this represents a small subgroup requiring viral PCR testing, which is not routinely available 4

Long-term prevention: Oral prednisolone during acute RSV bronchiolitis does NOT prevent post-bronchiolitis wheezing or asthma at 5-year follow-up (42% vs 31% persistent wheezing, p=NS). 5

Treatment Algorithm

For Adults and School-Age Children:

1. Assess severity: Measure peak expiratory flow, respiratory rate, heart rate 1
2. If severe features present (PEF <50%, RR >25, HR >110): Give prednisone 40-60 mg immediately 1
3. If incomplete response to bronchodilators: Give prednisone 40 mg daily for 1 week 1
4. Continue for 5-7 days without tapering 1

For Preschool Children (10 months to 6 years):

1. Do NOT routinely prescribe oral corticosteroids for virus-induced wheezing 2
2. Provide supportive care: Adequate hydration, analgesia (ibuprofen or acetaminophen), bronchodilators as needed 1
3. Consider prednisolone only if: Severe airway compromise threatening respiratory failure 1
4. If used: 1-2 mg/kg/day for 3-5 days maximum 1, 2

Critical Pitfalls to Avoid

• Do not delay prednisone in adults with severe asthma—mortality risk increases with undertreatment 1
• Do not use prednisone as monotherapy—always combine with bronchodilators for asthma 1
• Do not prescribe routinely for preschool viral wheeze—evidence shows no benefit and exposes children to unnecessary steroid side effects 2
• Do not confuse cough-variant asthma with viral bronchiolitis—the former responds to steroids, the latter does not 1, 2
• Exclude other diagnoses before escalating therapy: gastroesophageal reflux, improper inhaler technique, or non-asthmatic eosinophilic bronchitis 1

Adverse Effects Considerations

Short courses (5-7 days) of oral corticosteroids can cause insomnia, mood changes, and gastrointestinal disturbances but generally avoid the serious long-term complications (osteoporosis, cardiovascular disease, immunosuppression) seen with chronic use. 6 The risk-benefit ratio strongly favors treatment in adults with acute severe asthma but not in preschool children with viral wheeze. 1, 2