What prednisone dose and regimen should be used for an elderly patient with an acute asthma exacerbation, considering weight and comorbidities?

Prednisone Dosing for Acute Asthma Exacerbation in the Elderly

Administer prednisone 40–60 mg orally once daily (or divided into two doses) for 5–10 days without tapering, regardless of the patient's age, weight, or comorbidities. 1

Standard Dosing Regimen

• The recommended dose is 40–60 mg daily for all adults, including elderly patients, with no adjustment needed for age or body weight. 1
• Oral administration is strongly preferred and provides efficacy equivalent to intravenous therapy when gastrointestinal absorption is intact. 1
• The total course typically lasts 5–10 days, continuing until peak expiratory flow reaches ≥70% of predicted or the patient's personal best. 1

No Tapering Required

• For courses lasting 5–10 days, no tapering is necessary, especially when patients are concurrently using inhaled corticosteroids. 1
• Tapering short courses is unnecessary and may lead to under-dosing during the critical recovery period. 1, 2, 3
• High-quality randomized controlled trials demonstrate that abruptly stopping prednisone after 7–10 days produces outcomes identical to gradual tapering, with no rebound exacerbations. 2, 3

Dosing Algorithm by Severity

• Moderate exacerbations (peak expiratory flow 40–69% predicted, patient can speak in sentences): Start with prednisone 40 mg daily. 1
• Severe exacerbations (peak expiratory flow <50% predicted, difficulty completing sentences, respiratory rate ≥25/min, heart rate ≥110/min): Use prednisone 60 mg daily or the higher end of the 40–80 mg range. 1
• Higher doses beyond 60–80 mg provide no additional clinical benefit but increase adverse-effect risk. 1

Special Considerations for Elderly Patients

• The standard adult dose of 40–60 mg applies to elderly patients without dose reduction. 1
• Weight-based dosing is not used in adults; the fixed 40–60 mg range applies regardless of body weight. 1
• Comorbidities do not alter the prednisone dose, though they may influence monitoring parameters (e.g., blood glucose in diabetics, blood pressure in hypertensives). 1

Route Selection

• Oral prednisone is as effective as intravenous methylprednisolone or hydrocortisone and is less invasive. 1, 4, 5
• Reserve intravenous corticosteroids (hydrocortisone 200 mg initially, then 200 mg every 6 hours) only for patients who are actively vomiting, severely ill and unable to tolerate oral intake, or have impaired gastrointestinal absorption. 1
• A randomized controlled trial in hospitalized adults demonstrated no difference in peak expiratory flow improvement between oral prednisolone 100 mg daily and intravenous hydrocortisone 100 mg every 6 hours. 4

Timing and Concurrent Therapy

• Administer systemic corticosteroids immediately upon recognition of a moderate-to-severe exacerbation; do not delay while "trying bronchodilators first." 1
• Anti-inflammatory effects require 6–12 hours to become clinically apparent, making early administration essential. 1, 6
• Combine prednisone with high-dose inhaled short-acting β₂-agonists (albuterol 2.5–5 mg nebulized or 4–8 puffs via MDI with spacer every 20 minutes for three doses). 7
• Add ipratropium bromide 0.5 mg to albuterol for all moderate-to-severe exacerbations. 7

Common Pitfalls to Avoid

• Do not reduce the dose based on age alone; elderly patients require the same 40–60 mg dose as younger adults. 1
• Do not use weight-based dosing in adults; the fixed 40–60 mg range is standard. 1
• Do not taper courses lasting less than 10 days; abrupt cessation after achieving clinical stability is appropriate. 1, 2, 3
• Do not delay corticosteroid administration while attempting bronchodilator therapy alone; both must be given concurrently. 1
• Underuse of systemic corticosteroids is a documented factor in preventable asthma deaths. 1

Monitoring and Discharge Criteria

• Continue treatment until peak expiratory flow reaches ≥70% of predicted or personal best, symptoms are minimal, and the patient is stable for 30–60 minutes after the last bronchodilator dose. 1
• Ensure the patient is discharged on or continues inhaled corticosteroids at a higher dose than pre-exacerbation. 1
• Provide a written asthma action plan and verify correct inhaler technique before discharge. 1