Inhaled Corticosteroid Management During Asthma Exacerbations
Primary Recommendation
For patients experiencing an asthma exacerbation, do not increase the dose of inhaled corticosteroids (ICS) as acute treatment—instead, initiate systemic oral corticosteroids immediately while continuing maintenance ICS at the current dose. 1, 2
Evidence Against Increasing ICS During Exacerbations
The 2020 National Asthma Education and Prevention Program guidelines conditionally recommend against short-term increases in ICS dose (doubling, quadrupling, or quintupling) for increased symptoms or decreased peak flow in patients aged 4 years and older with mild to moderate persistent asthma who are adherent to daily ICS treatment. 1
- In children aged 4-11 years, quintupling the ICS dose at early signs of loss of control did not reduce exacerbations requiring systemic corticosteroids and showed a trend toward growth suppression (P=0.06). 1
- In individuals aged 12 years and older, temporary ICS dose increases did not significantly reduce exacerbations or hospitalizations. 1
- The certainty of evidence is low for exacerbations and moderate for quality of life, leading to a conditional recommendation against this practice. 1
Correct Acute Management Algorithm
Step 1: Initiate Systemic Corticosteroids Immediately
Adults: Prednisone 40-60 mg orally daily (single or divided doses) for 5-10 days without tapering. 2, 3
Children: Prednisone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days without tapering. 2, 3
- Oral administration is equally effective as intravenous therapy and strongly preferred when gastrointestinal absorption is intact. 2, 3
- Systemic corticosteroids should be administered early, as anti-inflammatory effects require 6-12 hours to become apparent. 2, 3
- No tapering is necessary for courses lasting 5-10 days, especially if patients are concurrently taking ICS. 2
Step 2: Continue Maintenance ICS at Current Dose
Patients should continue their regular daily ICS throughout the exacerbation and systemic corticosteroid course. 2, 4
- Do not stop ICS during acute exacerbations. 4
- Maintenance ICS therapy should be continued at the pre-exacerbation dose. 2
Step 3: Concurrent Bronchodilator Therapy
Administer albuterol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses, then every 1-4 hours as needed. 4, 3
Add ipratropium bromide 0.5 mg to beta-agonist therapy for moderate-to-severe exacerbations. 4, 3
Step 4: Reassess and Monitor
Measure peak expiratory flow 15-30 minutes after starting treatment and continue monitoring according to response. 4, 3
Continue treatment until PEF reaches ≥70% of predicted or personal best. 2, 4
Special Consideration: Non-Adherent Patients
For patients aged 16 years and older whose adherence to daily ICS therapy is not assured, clinicians can consider quadrupling the regular daily ICS dose at the first sign of deterioration. 1, 2
- This strategy may result in nearly 20% reduction in exacerbations in poorly adherent patients. 2
- However, this approach is not recommended for adherent patients, as controlled trials show no benefit. 1, 2
Post-Exacerbation ICS Management
After stabilization, consider initiating or increasing ICS maintenance therapy to a higher dose than pre-exacerbation levels to prevent future exacerbations. 2, 4
Ensure patients are discharged on appropriate maintenance ICS at least 48 hours before hospital discharge. 2
Critical Pitfalls to Avoid
- Do not delay systemic corticosteroids while attempting to increase ICS doses—this is ineffective and delays appropriate treatment. 1, 2
- Do not routinely double or quadruple ICS doses during exacerbations in adherent patients, as this provides no additional benefit. 1
- Do not stop maintenance ICS during acute exacerbations or systemic corticosteroid courses. 2, 4
- Underuse of systemic corticosteroids is a documented factor in preventable asthma deaths. 2