Is administering steroids, such as prednisone (corticosteroid) or fluticasone propionate (inhaled corticosteroid), at night a suitable approach for patients with conditions like asthma or chronic obstructive pulmonary disease (COPD) that worsen at night?

Timing of Steroid Administration in Asthma and COPD

Oral systemic corticosteroids should be taken as a single morning dose or in divided doses throughout the day—NOT specifically at night—because morning administration is endocrinologically preferable and aligns with the body's natural cortisol rhythm. 1

Evidence-Based Timing Recommendations

Systemic (Oral) Corticosteroids

Morning dosing is the standard of care for oral corticosteroids. The European Respiratory Society guidelines explicitly note that without specific instructions, one-third of patients incorrectly spread steroid tablets throughout the day or take them at times other than morning, which is "endocrinologically preferable." 1 This reflects the body's natural cortisol peak in early morning hours.

For acute exacerbations:

• Prednisone 40-60 mg daily should be given as a single morning dose or in 2 divided doses (not specifically at night) 2
• The timing priority is early administration (within 1 hour of presentation for moderate-to-severe exacerbations), not nighttime dosing 2
• Anti-inflammatory effects take 6-12 hours to become apparent, making early—not delayed nighttime—administration crucial 2

Inhaled Corticosteroids for Nocturnal Symptoms

This is where nighttime administration has demonstrated benefit. A single dose of inhaled corticosteroid (beclomethasone 1000 mcg or fluticasone 1000 mcg) administered at 16:00 hours (4 PM) significantly reduced overnight FEV1 decline in patients with nocturnal asthma, with fluticasone reducing the mean overnight fall from 0.65 L (placebo) to -0.02 L (p=0.019). 3

For patients with nocturnal worsening:

• Long-acting β2-agonists are specifically reserved for symptomatic treatment of nocturnal dyspnea in COPD 1
• Sustained release oral bronchodilators (terbutaline) are equivalent to inhaled steroids for controlling nocturnal symptoms 1
• Inhaled corticosteroids can be timed in late afternoon/evening to address nocturnal symptoms 3

Critical Clinical Algorithm

For maintenance therapy:

1. Administer oral corticosteroids in the morning as single dose 1, 2
2. If splitting doses, use morning and midday—not bedtime 2
3. Reserve evening/nighttime dosing specifically for inhaled corticosteroids when targeting nocturnal symptoms 3

For acute exacerbations:

1. Administer immediately upon recognition, regardless of time of day 2
2. Continue as morning dosing once stabilized 1
3. Do not delay treatment to wait for nighttime administration 2

Common Pitfalls to Avoid

Do not instruct patients to take oral systemic corticosteroids at night. This contradicts endocrinologic principles and established guidelines. 1 The confusion may arise from:

• Nocturnal asthma symptoms being common (which should prompt consideration of inhaled corticosteroids or long-acting bronchodilators timed for evening use) 1, 3
• The need for around-the-clock anti-inflammatory coverage (which is achieved through morning dosing, not nighttime dosing) 2

Do not assume nighttime worsening requires nighttime steroid dosing. Instead, optimize overall asthma control with appropriate maintenance therapy and consider evening-timed inhaled corticosteroids or long-acting bronchodilators. 1, 3