What is the recommended steroid regimen for managing asthma, including maintenance therapy and treatment of acute exacerbations?

Steroid Treatment for Asthma

Maintenance Therapy with Inhaled Corticosteroids

Inhaled corticosteroids are the cornerstone of long-term asthma control and should be prescribed as first-line therapy for all patients with persistent asthma. 1

Starting Doses for Maintenance Therapy

• Begin with low-dose inhaled corticosteroids (equivalent to budesonide 200-400 mcg/day, fluticasone 100-250 mcg/day, or mometasone 200 mcg/day) for patients with mild persistent asthma 1
• For moderate persistent asthma, start with low-dose ICS plus a long-acting beta-agonist (LABA) or medium-dose ICS monotherapy 1
• For severe persistent asthma, initiate high-dose ICS plus LABA as the preferred controller treatment 1

Critical Safety Consideration

Never prescribe LABAs as monotherapy—they must always be combined with inhaled corticosteroids due to FDA black-box warnings. 1

Dose-Response Relationship

The dose-response curve for inhaled corticosteroids is relatively flat, with 80-90% of maximum therapeutic benefit achieved at low doses (200-250 mcg fluticasone equivalent daily) 2, 3. Higher doses provide minimal additional benefit but significantly increase the risk of systemic side effects 4, 3. This means that escalating to high-dose ICS monotherapy often yields diminishing returns compared to adding a second controller medication 1, 2.

Alternative Controller Options

• Leukotriene modifiers (montelukast, zileuton) are appropriate alternatives for patients unable or unwilling to use inhaled corticosteroids, though they are less effective than ICS 1
• Combination ICS/LABA inhalers (fluticasone/salmeterol, budesonide/formoterol) improve compliance and control asthma at lower corticosteroid doses 1

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Treatment of Acute Exacerbations

Administer systemic corticosteroids immediately for all moderate-to-severe asthma exacerbations—do not delay while "trying bronchodilators first." 5, 6

Systemic Corticosteroid Dosing for Acute Exacerbations

Adults

• Prednisone 40-60 mg orally daily (single dose or divided into 2 doses) until peak expiratory flow reaches 70% of predicted or personal best 1, 5, 6
• Duration: 5-10 days for outpatient management 1, 5, 6
• No tapering is necessary for courses less than 10 days, especially if the patient is concurrently taking inhaled corticosteroids 1, 5, 6

Children

• Prednisone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days 1, 5, 6
• Calculate dose based on ideal body weight in significantly overweight children to avoid excessive steroid exposure 6
• No tapering required for short courses 5, 6

Route of Administration

• Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact 1, 5, 6
• Use IV hydrocortisone 200 mg immediately, then 200 mg every 6 hours only if the patient is vomiting, severely ill, or unable to tolerate oral medications 5, 6

Bronchodilator Therapy for Exacerbations

• Albuterol (short-acting beta-agonist) is first-line treatment: 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 1, 5
• Add ipratropium bromide 0.5 mg to albuterol for all moderate-to-severe exacerbations (every 20 minutes for 3 doses, then as needed), as this combination reduces hospitalizations 1, 5

Adjunctive Therapies for Severe/Refractory Exacerbations

• Intravenous magnesium sulfate 2 g over 20 minutes for severe exacerbations with FEV₁ or PEF <40% predicted after initial treatment or life-threatening features 5
• Oxygen supplementation to maintain SpO₂ >90% (>95% in pregnant patients or those with heart disease) 5

Severity Assessment and Hospital Admission Criteria

Assess severity objectively within 15-30 minutes using peak expiratory flow or FEV₁—subjective clinical impression alone frequently underestimates severity. 5

Severe Exacerbation Features:

• Inability to complete sentences in one breath 5
• Respiratory rate >25 breaths/min 5
• Heart rate >110 beats/min 5
• PEF <50% of predicted or personal best 5

Life-Threatening Features Requiring Immediate ICU Consideration:

• PEF <33% predicted 5
• Silent chest, cyanosis, or feeble respiratory effort 5
• Altered mental status, confusion, or drowsiness 5
• PaCO₂ ≥42 mmHg (normal or elevated in a breathless patient is ominous) 5
• Bradycardia or hypotension 5

Discharge Criteria

Patients may be discharged when: 5

• PEF ≥70% of predicted or personal best
• Symptoms are minimal or absent
• Oxygen saturation is stable on room air
• Patient is stable for 30-60 minutes after the last bronchodilator dose

Ensure patients continue oral corticosteroids for 5-10 days after discharge and initiate or continue inhaled corticosteroids at higher doses than pre-admission. 5, 6

Critical Pitfalls to Avoid

• Never administer sedatives to patients with acute asthma—this is absolutely contraindicated 5
• Do not delay corticosteroid administration while trying bronchodilators first, as anti-inflammatory effects require 6-12 hours to manifest 5, 6
• Do not underestimate severity by failing to measure PEF or FEV₁ objectively 5
• Avoid unnecessarily high doses of corticosteroids (>60 mg prednisone), as they provide no additional benefit but increase adverse effects 6
• Do not routinely double inhaled corticosteroid doses during exacerbations in adherent patients—this strategy is ineffective 1, 5