Is it safe to use prednisone in patients with influenza, particularly those with underlying conditions such as asthma or chronic obstructive pulmonary disease (COPD)?

Prednisone Use in Influenza: Critical Safety Considerations

Do not initiate prednisone for the treatment of influenza itself, as corticosteroids significantly increase mortality (OR 3.06) and secondary bacterial infections in influenza patients. 1

When Prednisone is Absolutely Contraindicated

• Never add corticosteroids thinking they will reduce inflammation in influenza pneumonia—they increase mortality, delay viral clearance, prolong ICU stays, and increase secondary bacterial infections. 1
• A meta-analysis of 13 observational studies (n=1,917 patients) demonstrated a mortality odds ratio of 3.06 (95% CI: 1.58-5.92) against corticosteroid use in influenza. 1
• Analysis of four low-bias trials confirmed these findings (OR: 2.82; 95% CI: 1.61-4.92) with increased risk of superinfection. 1

Critical Exceptions: When Steroids MUST Be Continued

If your patient is already on chronic prednisone, do not abruptly stop it—this creates a separate and immediate danger from adrenal insufficiency. 1

Continue Existing Steroids For:

• Patients on chronic steroids (≥20 mg/day prednisolone for >1 month): Continue at the lowest possible dose to control the underlying disease while treating influenza aggressively with antivirals. 1
• Patients receiving >5 mg/day prednisone equivalent: Avoid abrupt cessation due to adrenal suppression risk. 1
• Rheumatic disease patients: Continue glucocorticoids but reduce to the lowest possible dose to control the underlying disease. 1

New Indication During Influenza:

• COPD exacerbation triggered by influenza: Systemic corticosteroids are indicated specifically for the COPD exacerbation itself (not for influenza treatment), combined with oseltamivir, short-acting bronchodilators, and antibiotics. 2
• Asthma exacerbation: Continue inhaled corticosteroids for asthma management; may require systemic steroids specifically for asthma exacerbation, not for influenza itself. 1

Proper Management Algorithm

Step 1: Immediate Antiviral Therapy

• Initiate oseltamivir 75 mg orally twice daily for 5 days immediately in all hospitalized patients with suspected influenza, patients with severe or progressive illness, and high-risk patients (including those with chronic respiratory disease, immunosuppression, age <2 years or ≥65 years). 1, 3, 2
• Treatment should ideally begin within 48 hours of symptom onset, though high-risk patients may benefit even when started later. 3

Step 2: Risk Stratification

High-risk patients requiring aggressive monitoring include: 4

• Patients with chronic respiratory disease (asthma, COPD)
• Patients on immunosuppressive doses of steroids (≥20 mg/day prednisolone for >1 month)
• Age ≥65 years or <2 years
• Pregnant/postpartum women
• Chronic heart disease, diabetes, renal disease, liver disease

Step 3: Assess for Complications

• Calculate CURB-65 score immediately for suspected influenza-related pneumonia: score ≥2 indicates severe pneumonia requiring hospitalization. 2
• Investigate and empirically treat bacterial coinfection if: severe initial presentation, clinical deterioration after initial improvement, or failure to improve after 3-5 days of antiviral treatment. 1
• Monitor at least twice daily for temperature, respiratory rate, pulse, blood pressure, and oxygen saturation. 2

Step 4: Manage Underlying Conditions

• For COPD exacerbation: Add systemic corticosteroids, short-acting bronchodilators, and antibiotics to oseltamivir. 2
• For asthma exacerbation: Continue inhaled corticosteroids; add systemic steroids only if indicated for asthma severity, not for influenza. 1
• For chronic steroid users: Continue at lowest effective dose while prioritizing immediate antiviral therapy. 1

Common Pitfalls to Avoid

• Never add corticosteroids to "help" with influenza symptoms or inflammation—this is the most dangerous error, increasing mortality threefold. 1
• Never abruptly stop chronic steroids in patients who develop influenza—taper gradually while treating influenza with antivirals to avoid adrenal crisis. 1
• Do not withhold oseltamivir from high-risk patients (including those on chronic steroids) even if presenting slightly beyond 48 hours, as they may still benefit significantly. 3
• Do not prescribe zanamivir to patients with any underlying airways disease (asthma, COPD)—use oseltamivir instead, as zanamivir can cause fatal bronchospasm. 3

Warning Signs Requiring Immediate Re-evaluation

Patients should reconsult immediately if they experience: 2

• Shortness of breath at rest or with minimal activity
• Painful or difficult breathing
• Coughing up bloody sputum
• Drowsiness or altered mental status
• Lack of improvement after 2 days of oseltamivir
• Worsening of pre-existing medical conditions