What prednisone dose and tapering schedule should be used for an adult with an acute asthma exacerbation?

Prednisone Dosing for Acute Asthma Exacerbations in Adults

For adults with an acute asthma exacerbation, prescribe oral prednisone 40–60 mg once daily for 5–10 days without tapering, continuing until peak expiratory flow reaches ≥70% of predicted or personal best. 1

Recommended Dosing Algorithm

Standard Outpatient Regimen

• Administer prednisone 40–60 mg orally as a single morning dose or divided into two doses daily for 5–10 days. 1
• The 40 mg dose is appropriate for moderate exacerbations (peak flow 40–69% predicted, able to speak in sentences, respiratory rate <25/min, pulse <110/min). 2
• Use 60 mg for severe exacerbations (peak flow <50% predicted, difficulty completing sentences, respiratory rate ≥25/min, pulse ≥110/min, or oxygen desaturation). 2

Hospitalized Patients with Severe Exacerbations

• For patients requiring hospitalization, prescribe 40–80 mg daily in divided doses until peak expiratory flow reaches ≥70% of predicted. 1
• Continue treatment until two days after control is established, not for an arbitrary fixed period. 1

Route of Administration

Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact. 1

• Reserve IV 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. 2, 1
• There is no clinical advantage to intravenous administration over oral therapy when GI function is normal. 1

Duration and Tapering

No tapering is necessary for courses lasting 5–10 days, especially when patients are concurrently taking inhaled corticosteroids. 1

• The typical outpatient course lasts 5–10 days. 1
• Tapering short courses is unnecessary and may lead to underdosing during the critical recovery period. 1
• Treatment should continue until peak expiratory flow reaches ≥70% of predicted or personal best. 1

Critical Timing Considerations

Administer systemic corticosteroids immediately upon recognition of a moderate-to-severe exacerbation, not after repeated trials of bronchodilators alone. 1

• The anti-inflammatory effects of corticosteroids require 6–12 hours to become clinically apparent, making early administration essential. 1, 3
• Delaying corticosteroid therapy while repeatedly giving bronchodilators is a common and dangerous pitfall. 1
• Underuse of corticosteroids is a documented factor in preventable asthma deaths. 1

Concurrent Essential Therapy

• Nebulized albuterol 2.5–5 mg every 20 minutes for three doses, then every 1–4 hours as needed. 1
• Supplemental oxygen to maintain SpO₂ >92%. 1
• Add ipratropium bromide 0.5 mg to nebulized albuterol for severe exacerbations. 1
• Continue or increase inhaled corticosteroids at a higher dose than pre-exacerbation. 1

Monitoring Response

• Measure peak expiratory flow 15–30 minutes after initial treatment and reassess clinical status. 2, 1
• If no improvement after 15–30 minutes of bronchodilators plus corticosteroids, escalate care and consider hospital admission. 2
• Arrange follow-up within 1 week to reassess asthma control. 1

Important Clinical Pitfalls to Avoid

Do not use doses higher than 60–80 mg daily—higher doses provide no additional clinical benefit but increase adverse effects. 1

• Do not underdose by using only 20–30 mg daily; this is below the evidence-based minimum of 40 mg for acute exacerbations. 1
• Do not taper courses shorter than 7–10 days; this leads to underdosing during recovery. 1
• Do not delay systemic corticosteroids while giving repeated bronchodilators alone. 1
• Do not rely on clinical impression alone—always measure peak expiratory flow objectively. 1

Alternative Corticosteroid Options

• Prednisolone 40–60 mg daily can be substituted at equivalent doses. 1
• Methylprednisolone 60–80 mg daily is an alternative option. 1
• All oral corticosteroids are equally effective when given at equivalent doses. 1

Evidence Quality

These recommendations are based on high-quality evidence from the National Asthma Education and Prevention Program Expert Panel Report 3, the British Thoracic Society guidelines, and the American College of Allergy, Asthma, and Immunology. 1 A randomized controlled trial demonstrated that lower doses (hydrocortisone 50 mg IV four times daily) are as effective as higher doses (200–500 mg) in resolving acute severe asthma. 4