What is the appropriate dosage and usage of Prednisolone (a corticosteroid) for an adult or child with a condition such as asthma or an allergic reaction?

Prednisolone Dosing for Asthma and Allergic Reactions

For acute asthma exacerbations in adults, administer prednisolone 40-60 mg daily as a single morning dose for 5-10 days without tapering, and for children, give 1-2 mg/kg/day (maximum 60 mg/day) in 2 divided doses for 3-10 days without tapering. 1, 2

Adult Dosing Algorithm

Standard outpatient "burst" therapy:

• Prednisolone 40-60 mg daily as a single dose or in 2 divided doses for 5-10 days 1, 2
• Continue until peak expiratory flow (PEF) reaches 70% of predicted or personal best 1
• No tapering required for courses lasting 5-10 days, especially if concurrently taking inhaled corticosteroids 1

Severe exacerbations requiring hospitalization:

• Prednisolone 40-80 mg daily in divided doses until PEF reaches 70% of predicted 1
• May require 7-21 days of treatment depending on response 1

Route of administration:

• Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact 1
• Reserve IV hydrocortisone 200 mg every 6 hours only for patients who are vomiting, severely ill, or unable to tolerate oral medications 1

Pediatric Dosing Algorithm

Standard dosing:

• Prednisolone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days 1, 2
• Continue until PEF reaches 70% of predicted or personal best 1
• No tapering required for short courses 1

Alternative single-dose regimen for acute presentations:

• 30 mg for children under 5 years old 3
• 60 mg for children 5 years and older 3
• This single-dose approach significantly reduces hospital admission rates and duration of stay 3

Critical Timing Considerations

Administer systemic corticosteroids immediately:

• Within 1 hour of emergency department presentation for moderate-to-severe exacerbations 1
• Anti-inflammatory effects take 6-12 hours to become apparent, making early administration crucial 1
• Give to all patients not responding promptly to initial short-acting beta-agonist treatment 1

Evidence-Based Duration

The 5-day regimen is as effective as 10 days:

• High-quality randomized trial evidence demonstrates equivalence when patients receive concurrent inhaled corticosteroids 1, 4
• One study showed no significant difference in PEF or exacerbation rates between 5 and 10 days of prednisolone 40 mg daily 4
• Treatment may extend to 7-21 days if lung function has not returned to baseline 1

Dose Equivalency and Alternatives

If prednisolone is unavailable, equivalent alternatives include:

• Prednisone 40-60 mg daily (identical dosing to prednisolone) 1
• Methylprednisolone 48-72 mg daily (1.2x conversion factor) 1
• Hydrocortisone 200 mg IV every 6 hours (only if oral route contraindicated) 1

Lower doses are equally effective:

• Hydrocortisone 50 mg IV four times daily is as effective as 200 mg or 500 mg doses for resolving acute severe asthma 5
• However, one older study suggested 125 mg methylprednisolone every 6 hours provided faster improvement than 15 mg doses 6
• Current consensus favors moderate doses (40-60 mg prednisolone equivalent) as the optimal balance between efficacy and safety 1

Common Pitfalls to Avoid

Do not taper short courses:

• Tapering courses less than 7-10 days is unnecessary and may lead to underdosing during the critical recovery period 1
• Patients on concurrent inhaled corticosteroids do not require tapering even for 10-day courses 1

Do not use unnecessarily high doses:

• Higher doses of corticosteroids have not shown additional benefit in severe asthma exacerbations 1
• Doses above 60-80 mg daily increase adverse effects without improving outcomes 1

Do not delay administration:

• Delaying systemic corticosteroids during acute exacerbations leads to poorer outcomes 1
• Begin treatment immediately upon recognition of moderate-to-severe exacerbation 1

Do not use arbitrary 3-day courses:

• The 3-day duration is shorter than the evidence-based minimum of 5-10 days 1
• Treatment should continue until two days after control is established, not for an arbitrary period 1

Concurrent Essential Therapy

All patients require:

• Inhaled or nebulized beta-agonists (salbutamol 2.5-5 mg every 20 minutes for 3 doses, then every 1-4 hours as needed) 1
• Continuation or initiation of inhaled corticosteroids at higher doses than pre-exacerbation 7, 1
• Consider adding ipratropium bromide 0.5 mg to beta-agonist treatments in severe exacerbations 1

Monitoring Response

Objective measurements are essential:

• Measure PEF 15-30 minutes after starting treatment 1
• Continue monitoring according to response 1
• Target PEF ≥70% of predicted or personal best before discontinuing treatment 1
• Maintain oxygen saturation >92% with supplemental oxygen as needed 1

Safety Considerations

Short courses have minimal risks:

• Short courses of oral steroids produce very low rates of gastrointestinal bleeding 1
• Greatest risk occurs in patients with history of GI bleeding or those taking anticoagulants 1
• Any sedation is absolutely contraindicated during acute asthma exacerbations 8

Discharge Planning

Before discharge, ensure:

• Prednisolone 30-60 mg daily prescribed for completion of 5-10 day course 7
• Inhaled corticosteroids at higher dosage than before admission 7
• Peak flow meter provided with written self-management plan 7
• Follow-up with general practitioner within 1 week and respiratory physician within 1 month 7