In an adult with a moderate‑to‑severe asthma exacerbation, when should oral corticosteroids be used and what is the appropriate dosing regimen (including duration and taper), and how does this differ for children?

Oral Corticosteroids for Asthma Exacerbations

For adults with moderate-to-severe asthma exacerbations, administer oral prednisone 40–60 mg daily for 5–10 days without tapering; for children, give prednisone 1–2 mg/kg/day (maximum 60 mg/day) in two divided doses for 3–10 days without tapering. 1

When to Initiate Oral Corticosteroids

Start systemic corticosteroids immediately in all moderate-to-severe exacerbations or when patients fail to respond promptly to initial short-acting beta-agonist therapy. 1, 2 Do not delay corticosteroid administration while "trying bronchodilators first"—both should be given concurrently, as the anti-inflammatory effects of steroids require 6–12 hours to become clinically apparent. 1, 2 Underuse or delayed administration of systemic corticosteroids is a documented preventable cause of asthma-related deaths. 1, 3

Severity Indicators Requiring Immediate Steroids

• Moderate exacerbation: Dyspnea interfering with usual activity, respiratory rate >25 breaths/min, heart rate >110 beats/min, PEF 40–69% of predicted 1, 3
• Severe exacerbation: Dyspnea at rest, inability to complete sentences in one breath, PEF <50% of predicted 1, 3
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, altered mental status, PaCO₂ ≥42 mmHg 1, 3

Adult Dosing Regimen

Standard dose: Prednisone 40–60 mg orally once daily (or divided into two doses) for 5–10 days. 1 For severe exacerbations requiring hospitalization, use 40–80 mg/day in divided doses until PEF reaches ≥70% of predicted or personal best. 1

Alternative equivalent options: Prednisolone 40–60 mg/day or methylprednisolone 60–80 mg/day can be substituted at equivalent doses. 1

Route of Administration

Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact. 4, 1, 2 Reserve IV corticosteroids (hydrocortisone 200 mg immediately, then 200 mg every 6 hours) only for patients who are actively vomiting, severely ill and unable to tolerate oral intake, or have impaired GI absorption. 1, 3

Pediatric Dosing Regimen

Standard dose: Prednisone or prednisolone 1–2 mg/kg/day in two divided doses (maximum 60 mg/day) for 3–10 days. 4, 1, 2 The maximum daily dose is 60 mg regardless of weight. 1 For significantly overweight children, calculate the dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure. 1

Duration and Tapering

Total course duration: 5–10 days for outpatient management is standard. 4, 1, 2 Treatment should continue until PEF reaches ≥70% of predicted or personal best. 1, 2 For severe exacerbations, 7 days is often sufficient, but treatment may need to extend up to 21 days until lung function returns to the patient's previous best. 1

No tapering is necessary for courses lasting less than 7–10 days, especially if patients are concurrently taking inhaled corticosteroids. 4, 1, 2 Tapering short courses is unnecessary and may lead to underdosing during the critical recovery period. 1

Differences Between Adults and Children

The primary differences are:

• Dosing calculation: Adults receive a fixed dose (40–60 mg), while children receive weight-based dosing (1–2 mg/kg/day) with a 60 mg maximum 4, 1
• Dose frequency: Children should receive the dose divided twice daily, whereas adults can take it as a single morning dose or divided 1
• Duration range: Children may require shorter courses (3–10 days) compared to adults (5–10 days), though both ranges overlap 4, 1

Critical Pitfalls to Avoid

• Never delay corticosteroid administration while delivering repeated bronchodilator doses alone—steroids must be given immediately 1, 3
• Do not taper short courses (<7–10 days), as this leads to underdosing during the critical period 1
• Do not use unnecessarily high doses (>60–80 mg/day in adults), as higher doses have not shown additional benefit but increase adverse effects 1
• Never use sedatives in patients with acute asthma—they are absolutely contraindicated 3
• Do not rely on subjective assessment alone—always measure PEF or FEV₁ objectively to guide treatment 1, 3

Concurrent Essential Therapy

While administering oral corticosteroids, provide:

• High-dose inhaled beta-agonist: Albuterol 2.5–5 mg nebulized or 4–8 puffs via MDI with spacer every 20 minutes for three doses 1, 3, 2
• Ipratropium bromide: Add 0.5 mg to beta-agonist for moderate-to-severe exacerbations 1, 2
• Supplemental oxygen: Maintain SpO₂ >90% (>95% in pregnant patients or those with heart disease) 3, 2
• Continue or initiate inhaled corticosteroids at higher doses than pre-exacerbation 1, 2

Monitoring Response

Measure PEF 15–30 minutes after starting treatment and continue monitoring according to response. 1, 3 Reassess patients after the initial bronchodilator dose and after 60–90 minutes of therapy. 2 Continue treatment until PEF reaches ≥70% of predicted or personal best, symptoms are minimal, and the patient is stable for 30–60 minutes after the last bronchodilator dose. 1

Evidence Quality

These recommendations are based on high-quality evidence from the National Asthma Education and Prevention Program Expert Panel Report 3, British Thoracic Society guidelines, and multiple international consensus statements. 4, 1 The evidence consistently demonstrates that moderate-dose, 5–10 day courses of oral corticosteroids are as effective as higher doses or longer courses, with better safety profiles. 1, 2