What intravenous (IV) corticosteroid and dose are recommended for an acute asthma exacerbation in adults and children?

IV Steroid Dosing for Acute Asthma Exacerbation

Oral corticosteroids should be used as first-line therapy for acute asthma exacerbations in both adults and children; reserve intravenous administration only for patients who are actively vomiting, severely ill, or have impaired gastrointestinal absorption, as oral therapy provides equivalent efficacy while avoiding the invasiveness of IV access. 1

Route Selection Algorithm

Step 1: Assess oral tolerance

• If the patient can swallow and retain oral medication, administer oral prednisone/prednisolone immediately—this is equally effective as IV therapy and strongly preferred. 1, 2, 3
• Oral prednisone has effects equivalent to IV methylprednisolone but is less invasive. 1, 3

Step 2: When IV therapy is necessary

• Use IV corticosteroids only when the patient is vomiting, severely ill, or has documented impaired GI absorption. 1, 2, 3
• Choose either hydrocortisone or methylprednisolone—both are equally effective when dosed appropriately. 2, 3

IV Corticosteroid Dosing Regimens

Adults

Hydrocortisone (preferred IV option):

• Administer 100 mg IV every 6 hours (400 mg/day total) for adults who cannot tolerate oral therapy. 2
• Alternative dosing of 200 mg IV initially, then 200 mg every 6 hours has been recommended in some guidelines, though lower doses (100 mg every 6 hours) are equally effective. 1, 2

Methylprednisolone (alternative IV option):

• Administer 125 mg IV initially (dose range 40–250 mg), then repeat every 6 hours as needed. 1, 3
• Methylprednisolone 125 mg is roughly equivalent to hydrocortisone 500 mg in anti-inflammatory potency. 3

Pediatrics

Hydrocortisone:

• Administer 4–7 mg/kg IV every 8 hours (approximately 12–21 mg/kg/day divided into 3 doses). 1, 2
• Weight-based dosing is more appropriate than fixed doses for children. 2

Transition to Oral Therapy

• Switch to oral prednisone 40–60 mg daily for adults or 1–2 mg/kg/day (maximum 60 mg/day) for children as soon as oral intake is tolerated. 1, 3
• Continue oral therapy for 5–10 days total until peak expiratory flow reaches ≥70% of predicted or personal best. 1, 3
• No tapering is necessary for courses shorter than 7–10 days, especially when patients are concurrently receiving inhaled corticosteroids. 1

Concurrent Essential Therapies

• Provide high-flow oxygen (40–60%) to maintain SpO₂ >92% (>95% in pregnant women and patients with heart disease). 2, 3
• Administer nebulized albuterol 2.5–5 mg every 20 minutes for 3 doses initially, then every 1–4 hours as needed. 1, 3
• Add ipratropium 0.5 mg to nebulizers if inadequate response after 15–30 minutes. 1, 3

Monitoring Response

• Measure peak expiratory flow 15–30 minutes after initiating treatment and every 4 hours thereafter. 2, 3
• If no improvement after 15–30 minutes of bronchodilators and corticosteroids, escalate care and consider ICU transfer. 2
• Continue treatment until PEF reaches ≥70% of predicted or personal best. 1

Critical Pitfalls to Avoid

• Do not delay corticosteroid administration—systemic corticosteroids should be given within 1 hour of emergency department presentation, as their anti-inflammatory effects take 6–12 hours to become apparent. 1, 3
• Do not use unnecessarily high doses (>100 mg hydrocortisone every 6 hours in adults or >125 mg methylprednisolone): higher doses provide no additional benefit and increase adverse effects. 2, 4
• Do not continue IV therapy when oral is feasible—transition to oral as soon as the patient can tolerate it, as there is no therapeutic advantage to prolonged IV administration. 1, 5
• Do not taper short courses (5–10 days)—tapering is unnecessary and may lead to underdosing during the critical recovery period. 1, 3

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, and randomized controlled trials demonstrating equivalence between oral and IV routes when GI function is intact. 1, 5, 4