What is the recommended dosage of systemic corticosteroids, such as prednisone, for treating Acute Exacerbations of Bronchial Asthma (AEBA) in adults and children?

Systemic Corticosteroids in Acute Exacerbations of Bronchial Asthma (AEBA)

Recommended Dosing for Adults

For adults with acute asthma exacerbations, administer oral prednisone 40-60 mg daily as a single morning dose or in 2 divided doses for 5-10 days without tapering. 1, 2

• The dose should continue until peak expiratory flow (PEF) reaches 70% of predicted or personal best 1, 2
• For severe exacerbations requiring hospitalization, 40-80 mg/day in divided doses may be used until PEF reaches 70% of predicted 2
• Alternative equivalent options include prednisolone 30-60 mg daily or methylprednisolone 60-80 mg/day 2, 3
• Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact 1, 2, 4

Recommended Dosing for Children

For children with acute asthma exacerbations, administer oral prednisone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days without tapering. 1, 2

• Treatment continues until PEF reaches 70% of predicted or personal best 1, 2
• The maximum daily dose is 60 mg regardless of weight 2
• Alternative: prednisolone 1-2 mg/kg/day (maximum 40-60 mg) at equivalent doses 2, 4
• Methylprednisolone 0.25-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) is another option 2

Intravenous Administration (When Oral Route Not Feasible)

Reserve IV corticosteroids only for patients who are vomiting, severely ill, or unable to tolerate oral medications. 2, 4, 3

Adult IV Dosing:

• Hydrocortisone 100 mg IV every 6 hours (400 mg/day total) is the standard dose 4
• Alternative: hydrocortisone 200 mg IV immediately, then 200 mg every 6 hours 4, 3
• Methylprednisolone 125 mg IV (dose range 40-250 mg) can be used 2
• Lower doses (100 mg every 6 hours) are equally effective as higher doses (200 mg every 6 hours) and minimize adverse effects 4, 5

Pediatric IV Dosing:

• Hydrocortisone 4-7 mg/kg IV every 8 hours (approximately 12-21 mg/kg/day divided into 3 doses) 4
• Weight-based dosing is more appropriate than fixed doses for children 4

Critical Timing and Administration

Administer systemic corticosteroids within 1 hour of emergency department presentation for all moderate-to-severe exacerbations. 1, 2, 6

• Early administration significantly reduces hospital admission rates (OR 0.40,95% CI 0.21-0.78; number needed to treat = 8) 6
• Anti-inflammatory effects take 6-12 hours to become apparent, making early administration crucial 2, 3
• Corticosteroids should be given to patients not responding promptly to initial short-acting beta-agonist (SABA) treatment 1, 2

Duration and Tapering

For courses lasting 5-10 days, no tapering is necessary, especially if patients are concurrently taking inhaled corticosteroids. 1, 2

• The typical outpatient "burst" course lasts 5-10 days 1, 2
• For severe exacerbations, 7 days is often sufficient, but treatment may extend up to 21 days until lung function returns to baseline 2
• Treatment should continue until 2 days after control is established, not for an arbitrary 3-day period 2
• Tapering short courses (less than 7-10 days) is unnecessary and may lead to underdosing during the critical recovery period 2

Severity-Based Treatment Algorithm

Mild Exacerbations (PEF 70% or greater):

• Usually managed at home with increased SABA use 1
• Consider short course of oral corticosteroids if not responding promptly 1

Moderate Exacerbations (PEF 40-69%):

• Oral prednisone 40-60 mg daily for 5-10 days 1, 2
• Usually requires office or emergency department visit 1
• Frequent inhaled SABA therapy 1

Severe Exacerbations (PEF less than 40%):

• Oral prednisone 40-80 mg daily until PEF reaches 70% of predicted 1, 2
• Usually requires emergency department visit and likely hospitalization 1
• If vomiting or severely ill: IV hydrocortisone 100-200 mg every 6 hours 4, 3
• Adjunctive therapies including oxygen to maintain SpO2 greater than 92% 3

Life-Threatening (PEF less than 25%):

• Immediate IV hydrocortisone 200 mg, then 200 mg every 6 hours 3
• Requires emergency department hospitalization, possible intensive care unit 1, 3
• Continuous monitoring with arterial blood gases if PaO2 less than 8 kPa (60 mmHg) 3

Monitoring Response to Treatment

Measure peak expiratory flow 15-30 minutes after starting treatment and continue monitoring every 4 hours. 2, 4, 3

• Maintain oxygen saturation greater than 92% (greater than 95% in pregnant women and patients with heart disease) 4, 3
• If no improvement after 15-30 minutes of bronchodilators and corticosteroids, escalate care and consider ICU transfer 4, 3
• Reassess patients after initial bronchodilator dose and after 60-90 minutes of therapy 2
• Continue treatment until PEF reaches at least 70% of predicted or personal best 1, 2

Critical Pitfalls to Avoid

Do not delay corticosteroid administration—this is associated with increased mortality and poorer outcomes. 3, 6

• Do not use unnecessarily high doses: Higher doses (greater than 100 mg hydrocortisone every 6 hours or greater than 60 mg prednisone daily) provide no additional benefit and increase adverse effects 2, 4, 5
• Do not underestimate severity: Failure to make objective measurements (PEF, respiratory rate, oxygen saturation) can lead to inadequate treatment 2, 3
• Do not double inhaled corticosteroid doses during exacerbations—this is not effective 1
• Do not use sedatives—these are contraindicated in asthma exacerbations 3
• Do not prescribe antibiotics unless clear evidence of bacterial infection (pneumonia or sinusitis) exists 3
• Do not taper short courses (less than 7-10 days)—this may lead to underdosing during the critical recovery period 2

Evidence Quality and Strength

The recommendations are based on high-quality evidence from the National Asthma Education and Prevention Program Expert Panel Report 3 (EPR-3) guidelines 1, which represent the gold standard for asthma management in the United States. The dosing recommendations are further supported by multiple international guidelines including the British Thoracic Society 2, 3, American Academy of Allergy, Asthma, and Immunology 2, and systematic reviews demonstrating significant reduction in hospital admissions with early corticosteroid use 6. A randomized controlled trial demonstrated that low-dose hydrocortisone (50 mg IV every 6 hours) is equally effective as high-dose therapy (500 mg every 6 hours) 5, supporting the use of lower, safer doses.