What medications should be given to an adult or pediatric patient with asthma at the time of discharge from the hospital or emergency department?

Discharge Medications for Asthma Patients

All asthma patients being discharged from the hospital or emergency department must receive a combination of oral corticosteroids, inhaled corticosteroids at increased doses, and inhaled beta-agonists, along with a peak flow meter and written self-management plan. 1

Core Discharge Medications (Required for All Patients)

Oral Corticosteroids

• Adults: Prednisolone 30-60 mg daily for 7-14 days (some guidelines specify 1-3 weeks for severe cases) 1, 2, 3
• Pediatric patients: 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 4, 3
• Prednisolone must never be stopped or tapered if asthma symptoms are worsening 1

Inhaled Corticosteroids (ICS)

• Must be prescribed at a higher dosage than the patient was taking before admission 1, 2
• ICS treatment must be started at least 48 hours before discharge 1, 2
• Continue until first follow-up visit 1

Inhaled Beta-Agonists

• Inhaled or nebulized short-acting beta-agonists (SABA) for "as necessary" use 1
• Continue until first hospital follow-up visit 1
• Nebulizers should be replaced by standard metered-dose inhalers 24-48 hours before discharge unless home nebulizer is required 1, 2

Additional Medications (If Required)

Consider Adding:

• Oral theophylline if patient was using it during hospitalization 1
• Long-acting beta-agonists if needed for maintenance 1
• Inhaled ipratropium if required during hospital course 1

Essential Non-Medication Discharge Requirements

Peak Flow Meter and Self-Management Plan

• Every patient must receive a peak flow meter with comprehensive training on proper use 1, 2
• Written self-management plan is mandatory and must include: 1, 2
  • Specific PEF values at which to increase treatment
  • When to call their physician
  • When to return to emergency department or hospital

Inhaler Technique Verification

• Inhaler technique must be checked and documented before discharge 1, 2
• Alternative inhaler devices should be prescribed if technique is inadequate 1

Discharge Readiness Criteria

Patients must meet ALL of the following before discharge: 1, 2

• Been on discharge medications for at least 24 hours 1, 2
• Peak expiratory flow >75% of predicted or personal best 1, 2
• Diurnal PEF variability <25% 1, 2
• No nocturnal symptoms 1

Vaccination Considerations at Discharge

Pneumococcal Vaccination

• All asthma patients should receive pneumococcal vaccination before discharge as asthma is a high-risk condition 5
• Adults with asthma should receive the 23-valent pneumococcal polysaccharide vaccine regardless of age 5
• Immunocompromised patients require both 13-valent conjugate and 23-valent polysaccharide vaccines 5

Important Caveat

• Vaccination should not delay discharge if patient meets clinical stability criteria 5

Mandatory Follow-Up Arrangements

Must be scheduled before discharge: 1, 2

• Primary care physician visit within 1 week of discharge 1, 2
• Respiratory physician appointment within 4 weeks (1 month) 1, 2

Critical Pitfalls to Avoid

Common Errors That Increase Relapse Risk:

• Inadequate corticosteroid duration or dosing increases relapse rates significantly 2, 6
• Discharging before 24 hours on medications substantially increases treatment failure 2
• Failing to increase ICS dose above pre-admission levels leads to poor outcomes 2
• Not providing written action plan significantly increases relapse risk 2
• Evening discharges are associated with higher relapse rates 6

Medications to Avoid:

• Antibiotics should only be given if bacterial infection is documented 1
• Sedation is absolutely contraindicated 1

Special Considerations for Pediatric Patients

• Dosing is weight-based: prednisolone 1-2 mg/kg/day (maximum 40-60 mg/day) 1, 2, 4
• Written instructions should be provided to parents if child cannot self-manage 1
• Self-management plan must be age-appropriate 1