Inhaled Corticosteroids Should Be Continued During Oral Prednisone for Asthma Exacerbations
Do not stop the inhaled corticosteroid when starting oral prednisone for an asthma exacerbation—patients must continue their maintenance ICS throughout the systemic steroid course and beyond. 1
Evidence-Based Rationale
The National Asthma Education and Prevention Program explicitly states that maintenance ICS should not be stopped during acute exacerbations or systemic corticosteroid courses. 1 This recommendation is based on several key principles:
Systemic and inhaled corticosteroids work through different mechanisms and timeframes. Oral prednisone provides systemic anti-inflammatory effects that take 6-12 hours to become apparent, while inhaled corticosteroids deliver targeted airway anti-inflammatory action that should be maintained throughout the exacerbation and recovery period. 2, 3
Continuing ICS during oral steroid courses eliminates the need for tapering. For corticosteroid courses lasting 5-10 days, no tapering is necessary when patients are concurrently taking inhaled corticosteroids, as the ICS provides ongoing anti-inflammatory coverage during the transition off systemic therapy. 2, 1
Stopping ICS is a documented pitfall that worsens outcomes. The American College of Allergy, Asthma, and Immunology warns that discontinuing maintenance ICS during acute exacerbations delays appropriate treatment and is associated with poorer outcomes. 1
Practical Management Algorithm
During the Acute Exacerbation (Days 1-10)
Start oral prednisone 40-60 mg daily for adults (or 1-2 mg/kg/day, maximum 60 mg for children) for 5-10 days without tapering. 2, 3
Continue the current ICS dose that the patient was taking before the exacerbation—do not stop, do not increase during the acute phase. 1
Add high-dose short-acting beta-agonists (albuterol 4-12 puffs via MDI with spacer every 20-30 minutes for initial 3 treatments). 3
Post-Exacerbation Management (After Oral Steroid Course)
Increase the maintenance ICS dose to a higher level than pre-exacerbation to prevent future exacerbations, initiating this step-up at least 48 hours before completing the oral steroid course. 2, 1
Do not attempt to increase ICS doses as acute treatment during the exacerbation itself—evidence shows that quintupling ICS doses at early signs of loss of control does not reduce exacerbations requiring systemic corticosteroids and may cause growth suppression in children. 1
Why This Approach Is Superior
The evidence against stopping ICS is compelling:
Controlled trials demonstrate no benefit to increasing ICS during exacerbations in adherent patients aged 4 years and older, but continuing baseline ICS provides essential ongoing airway anti-inflammatory coverage. 1
The combination of systemic plus inhaled corticosteroids allows for shorter oral steroid courses without rebound, as the ICS maintains local airway control during the transition period. 2
Underuse of appropriate corticosteroid therapy (including premature discontinuation of ICS) is a documented factor in preventable asthma deaths. 2, 3
Critical Pitfalls to Avoid
Never delay systemic corticosteroids while attempting to increase ICS doses—this is ineffective and delays appropriate treatment. 1
Never stop maintenance ICS during acute exacerbations or systemic corticosteroid courses, as this eliminates the ongoing airway-specific anti-inflammatory effect. 1
Never routinely double or quadruple ICS doses during exacerbations in adherent patients, as this provides no additional benefit over continuing the baseline dose plus adding systemic steroids. 1