What is the recommended oral corticosteroid dose, duration, and taper for a moderate‑to‑severe asthma exacerbation in adults (and children)?

Oral Corticosteroid Dosing for Asthma Exacerbations

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

Adult Dosing Algorithm

Standard Outpatient Regimen

• Administer prednisone 40–60 mg 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, use prednisone 40–80 mg/day in divided doses until PEF reaches ≥70% of predicted. 1
• The oral route is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact. 1

Alternative Corticosteroid Options

• Prednisolone 30–60 mg daily can be substituted at equivalent doses. 1
• Methylprednisolone 60–80 mg/day is another alternative option. 1
• Dexamethasone 12–16 mg as a single dose or 16 mg daily for 2 days is at least as effective as the traditional 5-day prednisone course and may improve compliance. 2

When to Use Intravenous Therapy

• Reserve IV corticosteroids only for patients who are actively vomiting, severely ill, or unable to tolerate oral medications. 1
• If IV administration is necessary, use hydrocortisone 200 mg immediately, then 200 mg every 6 hours. 1
• Switch to oral therapy as soon as the patient can tolerate oral intake. 1

Pediatric Dosing Algorithm

Standard Regimen

• Prescribe prednisone or prednisolone 1–2 mg/kg/day (maximum 60 mg/day) in two divided doses for 3–10 days without tapering. 1
• Continue treatment until PEF reaches ≥70% of predicted or the child's personal best. 1
• The absolute daily dose must not exceed 60 mg regardless of weight. 1

Weight-Based Dosing Considerations

• For overweight children, calculate the dose using ideal body weight (approximately 25–30 kg for an 8-year-old) to avoid excessive steroid exposure and behavioral side effects. 1
• For mild-to-moderate exacerbations (child can speak in sentences, SpO₂ >92% on room air), start at 1 mg/kg/day. 1
• For severe exacerbations (difficulty speaking, SpO₂ <92%, poor response to initial bronchodilators), use 2 mg/kg/day (capped at 60 mg). 1

Alternative Single-Dose Option

• Dexamethasone 0.3 mg/kg as a single oral dose has been shown to be non-inferior to a 3–5-day course of prednisolone for mild-to-moderate exacerbations, offering easier administration and better compliance. 1, 3
• However, dexamethasone-treated children have a higher rate of requiring additional systemic steroids within 14 days (approximately 13% vs 4%), so prednisolone/prednisone remains the guideline-recommended standard. 1

Duration and Tapering

No Tapering Required

• For courses lasting 5–10 days, no tapering is necessary, especially when patients are concurrently taking inhaled corticosteroids. 1
• Tapering short courses is unnecessary and may lead to under-dosing during the critical recovery period. 1
• Treatment should continue until two days after control is established, not for an arbitrary 3-day period. 1

Treatment Duration by Setting

• Outpatient management: 5–10 days is typical for adults and 3–10 days for children. 1
• Hospitalized patients: 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

Critical Timing Considerations

Early Administration is Essential

• Administer systemic corticosteroids immediately upon recognition of a moderate-to-severe exacerbation or when patients fail to respond promptly to initial bronchodilator therapy. 1
• Anti-inflammatory effects require 6–12 hours to become clinically apparent, making early administration crucial to prevent respiratory failure and reduce mortality. 1, 2
• Delaying corticosteroid therapy while repeatedly giving bronchodilators alone is a common and dangerous pitfall. 1

Monitoring Response

• Measure peak expiratory flow 15–30 minutes after starting treatment and continue monitoring according to response. 1, 2
• If no improvement is observed within 15–30 minutes of the first bronchodilator and corticosteroid dose, escalate care and consider hospital admission. 1
• Response to treatment is a better predictor of hospitalization need than initial severity. 2

Concurrent Essential Therapies

Bronchodilator Therapy

• Administer nebulized salbutamol 5 mg (or 2.5 mg if weight <15 kg) via oxygen-driven nebulizer, or 4–8 puffs via metered-dose inhaler with spacer, every 20 minutes for three doses, then every 1–4 hours as needed. 1
• For severe exacerbations, add ipratropium bromide 0.5 mg (0.25 mg for children) to nebulized salbutamol; this combination reduces the risk of hospitalization. 1

Oxygen Therapy

• Deliver 40–60% oxygen via face mask to maintain SpO₂ >92% (>95% in pregnant women and patients with heart disease). 1, 2

Controller Medication

• Continue or initiate inhaled corticosteroids at a higher dose than the pre-exacerbation regimen throughout the steroid course and beyond. 1

Critical Pitfalls to Avoid

Dosing Errors

• Do not use unnecessarily high doses: Higher corticosteroid doses (>60–80 mg prednisone-equivalent per day) have not shown additional benefit in severe asthma exacerbations but increase the risk of adverse effects. 1, 2
• Do not underdose: Using arbitrarily short courses (like 3 days) without assessing clinical response may result in treatment failure. 1

Administration Errors

• Do not delay systemic corticosteroids: Under-use of corticosteroids is a documented factor in preventable asthma deaths. 1, 2
• Do not rely solely on clinical impression: Always measure peak expiratory flow objectively to assess severity and response. 1, 2
• Do not use IV therapy when oral is feasible: Oral administration is equally effective and less invasive when gastrointestinal absorption is intact. 1, 4

Contraindicated Interventions

• Do not give sedatives: These are contraindicated in asthma exacerbations and may be fatal. 2
• Do not prescribe antibiotics unless there is clear evidence of bacterial infection such as pneumonia or sinusitis. 2

Discharge Planning and Follow-Up

Discharge Criteria

• Ensure the patient has been stable on discharge medications for at least 24 hours, with PEF >75% of predicted and diurnal variability <25%. 1
• Verify correct inhaler technique and provide a written asthma action plan. 1

Follow-Up Schedule

• Arrange primary-care review within 1 week and a respiratory specialist appointment within 4 weeks after discharge. 1
• Provide a peak flow meter and written instructions for when to escalate treatment. 1

Evidence Quality Note

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 multiple randomized controlled trials demonstrating equivalence between oral and intravenous routes at appropriate dosing. 1, 4, 5