Discharge Medications for Asthma Patients
All asthma patients discharged from the hospital or emergency department must receive oral corticosteroids (prednisolone 30-60 mg daily for adults or 1-2 mg/kg/day for children), inhaled corticosteroids at higher doses than pre-admission, and inhaled beta-agonists for as-needed use. 1, 2
Core Discharge Medication Regimen
Oral Corticosteroids (Mandatory for All Patients)
- Adults: Prescribe prednisolone 30-60 mg daily for 1-3 weeks (or 7-14 days minimum) 1, 2, 3
- Pediatric patients: Prescribe prednisolone 1-2 mg/kg/day (maximum 40-60 mg/day) for 3-10 days 1, 2, 4
- No tapering is required after short courses of 7-14 days 2, 3
- Prednisolone must never be stopped or tapered if asthma symptoms are worsening 1
Inhaled Corticosteroids (Essential Component)
- Initiate or increase ICS to a higher dosage than before admission 1, 2
- ICS treatment must be started at least 48 hours before discharge 1, 2
- All patients receiving oral corticosteroids at discharge should also receive inhaled corticosteroids 2, 3
- ICS are essential for persistent asthma and should be initiated in the ED/hospital setting to ensure adherence 5
Inhaled Beta-Agonists
- Prescribe inhaled or nebulized beta-agonists for "as necessary" use 1
- Nebulizers should be replaced by standard metered-dose inhalers 24-48 hours before discharge unless home nebulizer is required 1, 2
- Patients must be stable on inhaler devices (not nebulizers) for 24-48 hours before discharge 1, 2
Additional Medications (If Required)
- Oral theophylline, long-acting beta-agonists, or inhaled ipratropium may be added if needed based on severity 1
- Monitor theophylline blood concentrations in patients requiring oral xanthines 1
Critical Pre-Discharge Requirements
Medication Stability Period
- Patients must be on discharge medications for at least 24 hours before discharge 1, 2
- Inhaler technique must be checked and documented 1, 2
Clinical Stability Criteria
- Peak expiratory flow (PEF) >75% of predicted or personal best 1, 2
- Diurnal PEF variability <25% 1, 2
- No nocturnal symptoms 1
Essential Non-Medication Discharge Components
Peak Flow Meter and Self-Management Plan
- Every patient must receive a peak flow meter with comprehensive training on its use 1, 2
- Provide a written self-management plan that includes specific PEF values for when to increase treatment, call their doctor, or return to the hospital 1, 2
Vaccinations (High Priority)
- Pneumococcal vaccination (23-valent polysaccharide vaccine) should be administered before discharge to all asthma patients, as asthma is a high-risk condition 6
- Immunocompromised patients should receive both 13-valent conjugate and 23-valent polysaccharide vaccines 6
- Influenza vaccination timing should be based on clinical stability 6
- Vaccination should not delay discharge if other clinical stability criteria are met 6
Follow-Up Arrangements (Mandatory)
- Primary care physician visit within 1 week of discharge 1, 2
- Respiratory physician appointment within 4 weeks 1, 2
Common Pitfalls to Avoid
- Inadequate duration or dosing of systemic corticosteroids significantly increases relapse risk 2
- Discharging patients before 24 hours on discharge medications increases treatment failure 2
- Failing to increase ICS dose above pre-admission levels leads to poor outcomes 2
- Not providing a written action plan dramatically increases relapse risk 2
- Stopping oral corticosteroids prematurely when asthma is still worsening is dangerous 1
Alternative Corticosteroid Route
While oral corticosteroids are standard, intramuscular corticosteroids (e.g., 160 mg depot methylprednisolone) may be considered as an alternative in patients with adherence concerns or inability to afford oral medications, as they show similar efficacy to oral regimens 7, 8. However, oral corticosteroids remain the preferred first-line approach 3, 9.