What is the role of prednisolone in asthma treatment, including indications, dosing for acute exacerbations in adults and children, duration, and tapering?

Role of Prednisolone in Asthma Treatment

Prednisolone is a cornerstone systemic corticosteroid for acute asthma exacerbations, administered orally at 40–60 mg daily for adults and 1–2 mg/kg/day (maximum 60 mg) for children, continued for 5–10 days without tapering, and should be given immediately—not after "trying bronchodilators first"—because its anti-inflammatory effect requires 6–12 hours to manifest. 1

Indications for Prednisolone

• Administer systemic corticosteroids early in all moderate-to-severe asthma exacerbations and in patients not responding promptly to initial short-acting beta-agonist therapy. 1, 2
• Prednisolone is indicated when peak expiratory flow (PEF) is 40–69% of predicted (moderate exacerbation) or <40% (severe exacerbation), when patients cannot complete sentences in one breath, or when respiratory rate exceeds 25 breaths/min in adults. 1, 2
• Delaying corticosteroid administration while repeatedly giving bronchodilators alone is a documented preventable cause of asthma deaths; steroids must be started immediately upon recognition of moderate or severe exacerbation. 1, 2

Adult Dosing

Standard Outpatient Regimen

• Prescribe oral prednisolone 40–60 mg once daily (or divided into two doses) for 5–10 days for adults with acute exacerbations. 1
• For severe exacerbations requiring hospitalization or emergency department care, use 40–80 mg/day in divided doses until PEF reaches ≥70% of predicted or personal best. 1
• The 40–60 mg range represents the optimal balance between efficacy and adverse effects; higher doses do not provide additional clinical benefit but increase side-effect risk. 1

Route of Administration

• Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact; there is no advantage to IV administration over oral. 1, 3
• Reserve IV hydrocortisone 200 mg immediately, then 200 mg every 6 hours, for patients who are actively vomiting, severely ill and unable to tolerate oral intake, or have impaired GI absorption. 1, 2
• A randomized controlled trial of 65 hospitalized adults found oral prednisolone 100 mg once daily produced identical improvement in PEF compared to IV hydrocortisone 100 mg every 6 hours over 72 hours (53.23% vs 55.87%, p=0.28). 3

Pediatric Dosing

• Give prednisolone 1–2 mg/kg/day in two divided doses (maximum 60 mg/day) for 3–10 days for children with acute exacerbations. 1
• The maximum daily dose is 60 mg regardless of weight; for significantly overweight children, calculate the dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure. 1
• A randomized double-blind study of 98 hospitalized children (ages 1–15 years) found no significant differences in clinical recovery between 0.5 mg/kg, 1.0 mg/kg, and 2.0 mg/kg daily doses, suggesting 0.5–1.0 mg/kg is appropriate. 4

Duration and Tapering

• The total course typically lasts 5–10 days for outpatient management; for courses less than 7–10 days, no tapering is necessary, especially if patients are concurrently taking inhaled corticosteroids. 1
• Tapering short courses is unnecessary and may lead to underdosing during the critical recovery period. 1
• Continue treatment until PEF reaches ≥70% of predicted or personal best, which typically occurs within the 5–10 day timeframe. 1
• For severe exacerbations requiring hospitalization, 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

Alternative Corticosteroid Options

• Prednisolone can be substituted with prednisone at equivalent doses (40–60 mg/day for adults; 1–2 mg/kg/day for children), as both are equally effective. 1
• Methylprednisolone 40–80 mg/day for adults or 0.25–2 mg/kg/day for children is another alternative at equivalent anti-inflammatory potency. 1
• Dexamethasone may offer advantages over prednisolone: a randomized trial of 175 children (ages 2–14 years) found oral dexamethasone 0.3 mg/kg in two doses 24 hours apart produced significantly better improvement in PRAM score, PEFR, and respiratory rate at 4 hours and 5 days compared to prednisolone 1 mg/kg twice daily for 5 days, with lower 6-hour emergency stay and admission rates (p<0.05) and less vomiting/gastritis. 5

Concurrent Essential Therapy

• Continue or initiate inhaled corticosteroids at a higher dose than pre-exacerbation during and after the systemic steroid course. 1, 2
• Administer nebulized or inhaled short-acting beta-agonists (albuterol 2.5–5 mg) every 20 minutes for three doses, then every 1–4 hours as needed. 1, 2
• Add ipratropium bromide 0.5 mg to beta-agonist therapy for all moderate-to-severe exacerbations, as this combination reduces hospitalizations. 1, 2
• Provide supplemental oxygen to maintain SpO₂ >90% (>95% in pregnant patients or those with heart disease). 2

Monitoring Response

• Measure PEF or FEV₁ before treatment and 15–30 minutes after the first bronchodilator dose to objectively assess severity and guide escalation decisions. 1, 2
• Continue monitoring PEF every 4 hours and reassess clinical status (symptoms, vital signs, oxygen saturation) throughout treatment. 1, 2
• Patients may be discharged when PEF reaches ≥70% of predicted or personal best, symptoms are minimal or absent, oxygen saturation is stable on room air, and the patient remains stable for 30–60 minutes after the last bronchodilator dose. 1, 2

Critical Pitfalls to Avoid

• Never delay systemic corticosteroid administration while "trying bronchodilators first"; both should be given concurrently in moderate-to-severe exacerbations. 1, 2
• Do not use unnecessarily high doses (>60 mg in adults), as higher doses have not shown additional benefit but increase adverse effects. 1
• Never administer sedatives of any kind to patients with acute asthma exacerbation, as this is absolutely contraindicated and may be fatal. 1, 2
• Do not rely solely on subjective clinical impression; objective PEF or FEV₁ measurement is essential to prevent underestimation of severity, which is the most common preventable cause of asthma deaths. 1, 2
• Do not underdose based on concerns about side effects; short courses (5–10 days) produce very low rates of gastrointestinal bleeding, with greatest risk only in patients with prior GI bleeding history or those taking anticoagulants. 1

Discharge Planning

• Ensure patients have been stable on discharge medications for at least 24 hours before discharge. 1, 2
• Verify correct inhaler technique and provide a written asthma action plan with peak-flow zones. 1, 2
• Prescribe or ensure the patient has a peak-flow meter if not already available. 1, 2
• Arrange primary-care follow-up within 1 week and respiratory specialist follow-up within 4 weeks. 1, 2
• Continue oral prednisolone for the full 5–10 day course after discharge; initiate or increase inhaled corticosteroid dose at discharge. 1, 2

Evidence Quality Note

These recommendations are based on high-quality evidence from the National Asthma Education and Prevention Program Expert Panel Report 3, British Thoracic Society guidelines, American Academy of Allergy, Asthma, and Immunology, and multiple international consensus statements. 1, 2