What is the recommended dose of prednisolone (corticosteroid) for an adult patient experiencing an acute exacerbation of asthma?

Prednisolone Dosing for Acute Asthma Exacerbations in Adults

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

Standard Dosing Algorithm

The recommended dose is prednisolone 40-60 mg daily (or prednisone equivalent) until peak expiratory flow reaches 70% of predicted or personal best. 1 This represents the consensus across major guidelines including the American College of Allergy, Asthma, and Immunology and National Asthma Education and Prevention Program. 1

Severity-Based Approach:

• Moderate exacerbations (PEF 40-69%): Prednisolone 40-60 mg daily for 5-10 days 1
• Severe exacerbations (PEF <40% or life-threatening features): Prednisolone 40-80 mg daily until PEF reaches 70% of predicted 1
• Very severe/hospitalized patients: Prednisolone 30-60 mg daily, or if unable to take oral medications, IV hydrocortisone 200 mg immediately, then 200 mg every 6 hours 2, 1

Route of Administration

Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact. 1 There is no advantage to IV administration over oral therapy provided the patient can swallow and is not vomiting. 1 Reserve IV hydrocortisone for patients who are vomiting, severely ill, or unable to tolerate oral medications. 1

Duration and Tapering

The total course typically lasts 5-10 days for outpatient management. 1 Treatment should continue until peak expiratory flow reaches at least 70% of predicted or personal best, which usually occurs within this timeframe. 1

No tapering is necessary for courses lasting less than 7-10 days, especially if patients are concurrently taking inhaled corticosteroids. 1 Tapering short courses is unnecessary and may lead to underdosing during the critical recovery period. 1

For severe exacerbations requiring hospitalization, 7 days is often sufficient, but treatment may need to extend up to 21 days until lung function returns to the patient's previous best. 1

Critical Timing Considerations

Administer systemic corticosteroids early—within 1 hour of presentation for all moderate-to-severe exacerbations. 1 The anti-inflammatory effects take 6-12 hours to become apparent, making early administration crucial for optimal outcomes. 1 Delay in corticosteroid administration is a documented cause of preventable asthma deaths. 2

Evidence on Dose Equivalence

Higher doses of corticosteroids (120-180 mg/day) have not shown additional benefit compared to standard doses (40-80 mg/day) in severe asthma exacerbations. 1 Research demonstrates that even lower doses can be effective: hydrocortisone 50 mg IV four times daily was as effective as 200 mg or 500 mg doses in resolving acute severe asthma. 3

Common Pitfalls to Avoid

• Do not underdose systemic corticosteroids—underuse of corticosteroids is a documented factor in preventable asthma deaths 2
• Do not delay administration while waiting for objective measurements; begin treatment immediately in suspected severe exacerbations 1
• Do not use unnecessarily high doses (>80 mg/day), as they increase adverse effects without additional clinical benefit 1
• Do not taper courses lasting 5-10 days, as this is unnecessary and may compromise treatment efficacy 1
• Do not use weight-based dosing in adults—the standard 40-60 mg range applies regardless of body weight 1

Concurrent Essential Therapy

Always combine prednisolone with:

• High-flow oxygen (40-60%) to maintain SpO2 >92% 2, 1
• Nebulized salbutamol 5 mg (or terbutaline 10 mg) every 4 hours initially, increasing to every 15-30 minutes if not improving 2, 1
• Ipratropium bromide 0.5 mg added to nebulizer if patient not improving after 15-30 minutes, repeated every 6 hours 2, 1

Monitoring Response

• Measure peak expiratory flow 15-30 minutes after starting treatment 2, 1
• Reassess after 60-90 minutes of therapy to determine need for escalation 1
• Continue treatment until PEF ≥70% of predicted or personal best 1
• Monitor oxygen saturation continuously with target SpO2 >92% 2, 1

Alternative Corticosteroid Options

If prednisolone is unavailable, equivalent alternatives include:

• Prednisone 40-60 mg daily (bioequivalent to prednisolone) 1
• Methylprednisolone 40-80 mg daily (slightly higher potency) 1
• IV hydrocortisone 200 mg every 6 hours (for patients unable to take oral medications) 2, 1