What is the recommended intravenous (IV) steroid regimen for a patient with severe asthma?

Oral Steroids Are Equally Effective as IV Steroids in Severe Asthma

Oral corticosteroids should be the preferred route for severe asthma exacerbations unless the patient is vomiting, severely ill and unable to swallow, or has impaired gastrointestinal absorption—in these specific circumstances, IV hydrocortisone 200 mg immediately followed by 200 mg every 6 hours is indicated. 1

Route Selection Algorithm

For patients who can tolerate oral intake:

• Administer oral prednisolone 30-60 mg daily as the first-line treatment 1
• Multiple high-quality guidelines explicitly state there is no advantage to IV administration over oral therapy when GI absorption is intact 1
• Oral administration is less invasive and equally effective 1

Switch to IV route only when:

• Patient is actively vomiting 1
• Patient is severely ill and unable to swallow 1
• Life-threatening features are present (PEF <33% predicted, silent chest, cyanosis, confusion, exhaustion) 1
• In these cases, give IV hydrocortisone 200 mg stat, then 200 mg every 6 hours 1

Evidence Supporting Oral Route Equivalence

The recommendation against routine IV steroids is supported by multiple randomized controlled trials:

• A 2011 study of 65 hospitalized adults with acute asthma exacerbations found no significant difference in peak flow improvement between oral prednisolone 100 mg daily versus IV hydrocortisone 100 mg every 6 hours over 72 hours 2
• A 1988 prospective study of 77 patients with status asthmaticus showed no differences in respiratory failure rates, FEV1 improvement, or hospitalization days between oral methylprednisolone (160-320 mg daily) versus IV methylprednisolone (500-1000 mg daily) 3
• A 1986 double-blind trial of 52 severely ill asthmatics demonstrated that adding IV hydrocortisone to oral prednisolone provided no additional benefit in peak flow recovery at 24 hours 4

Recommended Dosing Regimens

For adults with severe asthma:

• Oral prednisolone 40-80 mg daily until PEF reaches 70% of predicted or personal best 1
• Alternative: oral prednisone 40-80 mg daily in 1-2 divided doses 1
• If IV required: hydrocortisone 200 mg immediately, then 200 mg every 6 hours 1
• Alternative IV option: methylprednisolone 125 mg (range 40-250 mg) 1

Duration:

• Continue for 5-10 days typically 1
• May extend to 21 days if lung function has not returned to baseline 1
• No tapering needed for courses <7-10 days, especially if patient is on inhaled corticosteroids 1

Critical Timing Considerations

Administer systemic corticosteroids immediately because their anti-inflammatory effects take 6-12 hours to become apparent 1. Delaying corticosteroid administration is a documented factor in preventable asthma deaths 1.

Common Pitfalls to Avoid

• Do not routinely use IV steroids when oral route is feasible—this adds unnecessary invasiveness without clinical benefit 1
• Do not use excessively high doses—higher doses have not shown additional benefit in severe exacerbations 1
• Do not delay steroid administration while attempting to establish IV access if patient can swallow 1
• Do not taper short courses (<7-10 days)—this is unnecessary and may lead to underdosing during the critical recovery period 1

Concurrent Essential Therapy

While administering corticosteroids:

• Give high-flow oxygen 40-60% to maintain SpO2 >92% 1
• Administer nebulized salbutamol 5 mg (or terbutaline 10 mg) every 4 hours initially, increasing to every 30 minutes if not improving 1
• Add ipratropium bromide 0.5 mg to nebulizer if patient not improving after 15-30 minutes 1
• Measure peak expiratory flow 15-30 minutes after starting treatment to assess response 1