Should a patient with influenza and a history of asthma be given steroids?

Steroids in Influenza with Asthma: A Critical Decision

Yes, systemic corticosteroids should be given to patients with influenza who are experiencing an asthma exacerbation, but corticosteroids should NOT be given for the influenza infection itself. The key is distinguishing between treating the asthma exacerbation versus treating the influenza pneumonia.

The Critical Distinction

When Steroids ARE Indicated: Asthma Exacerbation

Patients with moderate-to-severe asthma exacerbations triggered by influenza require systemic corticosteroids using the same aggressive approach as any other viral trigger. 1

• Dosing: Prednisone 40-60 mg daily for 5-10 days without tapering is recommended for adults 1
• Pediatric dosing: 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days 1
• Timing: Start early, as anti-inflammatory effects require 6-12 hours to become apparent 1
• Route: Oral administration is equally effective as intravenous when gastrointestinal absorption is intact 1

The underuse of corticosteroids in asthma exacerbations is associated with increased mortality, regardless of the viral trigger 1. Influenza-triggered exacerbations warrant the same treatment as other causes 1.

When Steroids Are NOT Indicated: Influenza Pneumonia

Corticosteroids should not be administered for influenza infection itself, influenza-associated pneumonia, respiratory failure, or ARDS unless clinically indicated for other reasons. 2

• The Infectious Diseases Society of America explicitly recommends against corticosteroid adjunctive therapy for suspected or confirmed seasonal influenza (A-III recommendation) 2
• Meta-analysis of 13 observational studies (n=1,917) found an odds ratio of mortality of 3.06 (95% CI: 1.58-5.92) against corticosteroid use in influenza 3, 2
• Analysis of four low-bias trials showed consistent findings (OR: 2.82; 95% CI: 1.61-4.92) with increased risk of superinfection 2
• Corticosteroids may delay viral clearance and facilitate secondary bacterial infections 3, 2

Clinical Algorithm for Decision-Making

Step 1: Assess for Asthma Exacerbation

Look for these specific indicators 1:

• Symptoms more than twice per week
• Nighttime awakenings
• Short-acting β-agonist use more than twice per week
• Interference with normal activity
• Peak expiratory flow <70% of predicted or personal best
• Increased work of breathing, respiratory rate

If asthma exacerbation is present: Proceed to Step 2

If only influenza symptoms without asthma exacerbation: Do NOT give corticosteroids; treat with antivirals only 2

Step 2: Initiate Concurrent Therapy for Asthma Exacerbation

Corticosteroids:

• Start prednisone 40-60 mg daily immediately 1
• Continue for 5-10 days until peak flow reaches 70% of predicted 1
• No tapering needed for short courses up to 2 weeks 4

Bronchodilators:

• High-dose short-acting beta-agonists (albuterol 4-12 puffs via MDI with spacer or nebulized 2.5-5 mg) every 20-30 minutes for initial 3 treatments 1
• Add ipratropium bromide 0.5 mg to reduce hospitalizations 1

Antivirals for Influenza:

• Oseltamivir 75 mg orally twice daily for 5 days 3
• Start immediately regardless of time since symptom onset in severe cases 2

Antibiotics:

• All patients with influenza pneumonia should receive antibiotics to cover bacterial co-infection (S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus) 3

Step 3: Monitor Response

• Measure peak expiratory flow 15-30 minutes after starting treatment 1
• Reassess after initial bronchodilator dose and after 60-90 minutes 1
• Maintain oxygen saturation >90% (>95% in pregnant women and heart disease) 1

Critical Caveats and Pitfalls

Patients Already on Chronic Corticosteroids

Do NOT abruptly stop corticosteroids in patients already taking them chronically. 3, 2

• Continue necessary steroid therapy for chronic conditions (severe asthma, COPD) 3
• Attempt dose reduction to the lowest effective level to avoid adrenal insufficiency 3, 2
• Abrupt withdrawal in patients on >5 mg/day prednisone or equivalent can cause acute adrenal insufficiency 2, 5

Risk of Secondary Infections

• Corticosteroids increase risk of bacterial superinfection in influenza 3, 2
• Maintain high suspicion and low threshold for antibiotics 3
• Investigate bacterial coinfection if patient deteriorates after initial improvement or fails to improve after 3-5 days 2

Inhaled Corticosteroids Are Safe

• Inhaled corticosteroids for chronic asthma control do NOT increase the risk of influenza 6
• Continue maintenance inhaled corticosteroids throughout influenza illness 7, 8

The Bottom Line

The decision hinges on what you are treating: systemic corticosteroids are essential for asthma exacerbations (even when triggered by influenza) but harmful when given for influenza infection itself. Never withhold corticosteroids from a patient having an asthma exacerbation simply because influenza is the trigger, but equally, never add corticosteroids to treat the influenza component. This dual approach—aggressive asthma management with corticosteroids plus antiviral therapy for influenza—provides the best outcomes while minimizing harm. 1, 3, 2