What is the appropriate prednisone dosing for an adult with an acute moderate‑to‑severe asthma exacerbation?

Prednisone Dosing for Acute Asthma Exacerbations in Adults

For adults with acute moderate-to-severe asthma exacerbations, prescribe oral prednisone 40–60 mg once daily (or divided into two doses) for 5–10 days without tapering. 1

Dosing Algorithm Based on Severity

Moderate Exacerbations

• Administer prednisone 40–60 mg daily for patients presenting with peak expiratory flow (PEF) 40–69% of predicted, ability to speak in sentences, respiratory rate <25/min, and pulse <110/min. 1
• Continue treatment until PEF reaches ≥70% of predicted or the patient's personal best. 1

Severe Exacerbations

• Use prednisone 40–80 mg daily in divided doses for patients with PEF <50% predicted, difficulty completing sentences, respiratory rate ≥25/min, pulse ≥110/min, or oxygen desaturation. 1, 2
• For life-threatening features (PEF <33%, silent chest, confusion, exhaustion), consider the higher end of dosing (60–80 mg) or switch to IV hydrocortisone 200 mg immediately, then 200 mg every 6 hours. 2

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 initially, then 200 mg every 6 hours) exclusively for patients who are actively vomiting, severely ill, or unable to tolerate oral medications. 1, 2
• There is no clinical advantage to IV administration over oral therapy when the patient can swallow. 1, 3

Duration and Tapering

• The standard outpatient course lasts 5–10 days. 1
• No tapering is necessary for courses shorter than 7–10 days, especially when patients are concurrently taking inhaled corticosteroids. 1
• Tapering short courses is unnecessary and may lead to underdosing during the critical recovery period. 1
• A 5-day course appears to be as effective as a 10-day course when patients receive concurrent inhaled corticosteroids, based on randomized trial evidence. 4

Critical Timing Considerations

• Administer systemic corticosteroids immediately upon recognition of a moderate-to-severe exacerbation, ideally within 1 hour of presentation. 1
• The anti-inflammatory effects of corticosteroids require 6–12 hours to become clinically apparent, making early administration essential. 1, 2
• Delaying corticosteroid therapy while repeatedly giving bronchodilators alone is a dangerous and common pitfall. 1

Concurrent Essential Therapy

• Continue or initiate high-dose inhaled corticosteroids throughout the exacerbation and beyond. 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 treatments. 1, 2
• Provide supplemental oxygen to maintain SpO₂ >92% (>95% in pregnant women or patients with heart disease). 2

Monitoring Response

• Measure PEF 15–30 minutes after starting treatment and continue monitoring according to response. 1, 2
• If no improvement occurs within 15–30 minutes of initial bronchodilator and corticosteroid treatment, escalate care and consider hospital admission. 1, 2
• Reassess patients after 60–90 minutes of therapy. 1

Important Clinical Pitfalls to Avoid

• Never use doses higher than 60–80 mg prednisone-equivalent daily—higher doses provide no additional clinical benefit but increase adverse effects. 1
• Never delay systemic corticosteroids while delivering repeated bronchodilator doses alone; underuse of corticosteroids is a documented cause of preventable asthma deaths. 1, 2
• Never use sedatives in patients with acute asthma—they are absolutely contraindicated and can be fatal. 5
• Do not rely solely on clinical impression; objective measurement of PEF is required to assess severity accurately. 1
• Do not prescribe antibiotics unless there is clear evidence of bacterial infection (pneumonia or sinusitis). 2

Alternative Corticosteroid Options

• Prednisolone 40–60 mg daily can be substituted at equivalent doses. 1
• Methylprednisolone 40–80 mg daily is another alternative, though it offers no advantage over prednisone for oral therapy. 1
• All oral corticosteroids are equally effective when given at equivalent doses. 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 the American College of Allergy, Asthma, and Immunology. 1, 2 The 5–10 day regimen at 40–60 mg daily represents the standard of care for outpatient management of acute asthma exacerbations. 1