Prednisone Dosing for Asthma Exacerbation
For adults with acute asthma exacerbations, prescribe oral prednisone 40–60 mg once daily for 5–10 days without tapering; for children, prescribe 1–2 mg/kg/day (maximum 60 mg/day) in two divided doses for 3–10 days without tapering. 1
Adult Dosing Regimen
Administer prednisone 40–60 mg orally once daily (or divided into two doses) for 5–10 days until peak expiratory flow (PEF) reaches ≥70% of predicted or personal best. 1
For severe exacerbations requiring hospitalization or emergency department care, use 40–80 mg/day in divided doses until PEF reaches ≥70% of predicted. 1, 2
The standard dose range of 40–60 mg represents optimal efficacy; higher doses (>80 mg/day) provide no additional clinical benefit but increase adverse effects. 1
Pediatric Dosing Regimen
Prescribe prednisone or prednisolone 1–2 mg/kg/day in two divided doses (maximum 60 mg/day) for 3–10 days without tapering. 1, 3
For overweight children, calculate the dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure and associated side effects. 1
The 60 mg maximum daily dose applies regardless of the child's weight. 1
Route of Administration
Oral corticosteroids are strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact. 1, 4
Reserve intravenous therapy (hydrocortisone 200 mg immediately, then 200 mg every 6 hours) only for patients who are actively vomiting, severely ill, or unable to tolerate oral medications. 1, 2
A randomized controlled trial in 65 adults demonstrated that oral prednisolone 100 mg daily was equivalent to IV hydrocortisone 100 mg every 6 hours, with similar improvements in PEF after 72 hours (53.23% vs 55.87%, p=0.28). 4
Duration and Tapering
No tapering is necessary for courses lasting 5–10 days, especially when patients are concurrently taking inhaled corticosteroids. 1, 5
A randomized controlled trial of 35 patients demonstrated that abruptly stopping prednisolone after achieving stable PEF was equivalent to a 14-day taper, with no difference in lung function at 14 or 28 days post-discharge. 5
Continue treatment until PEF reaches ≥70% of predicted or personal best, which typically occurs within 5–10 days. 1
Critical Timing Considerations
Administer systemic corticosteroids immediately when a moderate-to-severe exacerbation is recognized, rather than after repeated bronchodilator trials. 1, 2
The anti-inflammatory effects of corticosteroids require 6–12 hours to become clinically apparent, making early administration essential to prevent respiratory failure. 1, 2
Underuse or delayed administration of corticosteroids is a documented preventable cause of asthma-related deaths. 1, 2
Alternative Corticosteroid Options
Prednisolone can be substituted at equivalent doses (40–60 mg/day for adults; 1–2 mg/kg/day for children). 1
Dexamethasone 0.3–0.6 mg/kg daily for 1–5 days is an alternative for children, with evidence showing similar efficacy to prednisone in reducing hospital admissions. 3
Methylprednisolone 40–80 mg/day for adults or 0.25–2 mg/kg/day for children is another equivalent option. 1
Concurrent Essential Therapies
Continue or initiate inhaled corticosteroids at a higher dose than the pre-exacerbation regimen. 1
Administer nebulized or inhaled short-acting β-agonists (albuterol 2.5–5 mg) every 20 minutes for three doses, then every 1–4 hours as needed. 1
For severe exacerbations, add ipratropium bromide 0.5 mg to β-agonist therapy to increase bronchodilation. 1, 2
Provide supplemental oxygen to maintain SpO₂ >92% (>95% in pregnant women). 2
Common Pitfalls to Avoid
Never delay corticosteroid administration while delivering repeated bronchodilator doses alone; this is a leading cause of preventable asthma deaths. 1, 2
Do not use unnecessarily high doses (>60–80 mg prednisone-equivalent); a Cochrane review of 18 studies (2438 participants) found no convincing evidence that higher doses improve outcomes. 6
Do not taper short courses (<7–10 days); tapering is unnecessary and may lead to underdosing during the critical recovery period. 1, 5
Do not rely solely on clinical impression; objective measurement of PEF is required to assess severity and response. 1, 2
Never use sedatives in acute asthma; they are contraindicated and potentially fatal. 2
Monitoring and Follow-Up
Measure PEF 15–30 minutes after initiating treatment and continue monitoring every 4 hours to assess response. 1, 2
Ensure patients have a written asthma action plan, verified inhaler technique, and a peak flow meter before discharge. 1
Arrange primary care follow-up within 1 week and respiratory specialist review within 4 weeks. 1