Asthma Management Handbook

Guide to systemic corticosteroids

Overview

Short courses of systemic corticosteroids are used to manage flare-ups and acute asthma. Oral prednisone/prednisolone is most commonly used. Parenteral corticosteroids are sometimes used to manage severe acute asthma in emergency departments.

Occasionally, longer-term use of oral corticosteroids is necessary to manage difficult-to-treat asthma under specialist supervision.

Table. Classification of asthma medicines Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/79

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Oral corticosteroids for children: 0–5 years

Few clinical trials have assessed the effectiveness of oral corticosteroids for managing flare-ups of wheezing in preschool children,1 and there is very little evidence about their effects in children who are not being treated in hospitals or emergency departments.

Short courses of oral corticosteroids initiated by parents in response to the onset of wheezing symptoms do not appear to reduce the need for hospitalisation or treatment in the emergency department for preschool children.1 For children age 1–5 years with wheezing due to a respiratory tract virus such as the common cold, a short course of oral prednisolone does not reduce the severity of symptoms.23

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Oral corticosteroids for children: 6 years and over

A short course of oral corticosteroid may be helpful in gaining rapid asthma control, with a low risk of additional systemic adverse effects.4

Rarely, long-term systemic corticosteroids may be needed for children with severe persistent asthma that is poorly controlled despite high-dose inhaled corticosteroids and long-acting beta2 agonists.4 However, significant adverse effects may occur due to recurrent or long-term systemic corticosteroids.4

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Oral corticosteroids for children: adverse effects

A short course of oral corticosteroid therapy (less than 2 weeks) is associated with little risk of long-term suppression of the hypothalamus–pituitary–adrenal axis.4 However, risk can accumulate if frequent courses (four or more per year) are given.4

Recurrent courses of oral corticosteroids may also affect bone mineral density, especially in boys.4

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Parent-initiated oral corticosteroid treatment in children

There is limited and inconclusive evidence from clinical trials evaluating the effectiveness of courses of oral corticosteroids initiated by parents in response to children’s wheezing.5

In children aged 6–14 years, a course of oral prednisolone initiated by parents in response to an asthma flare-up may reduce asthma symptoms and the number of missed school days.6

In children aged 1–5 years with episodic wheezing, oral corticosteroids are not effective in managing the symptoms of acute lower respiratory tract illnesses.7

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Managing flare-ups in adults: oral corticosteroids

The use of oral corticosteroids is accepted as part of the management of severe asthma flare-ups, including in most asthma clinical trials.

Most clinical trials that have specifically evaluated the use of oral corticosteroids to manage flare-ups have been conducted in patients attending emergency departments. Oral corticosteroids courses of 5–10 days are effective in regaining control of asthma after an acute flare-up.89101112 A 5-day course of prednisolone 40 mg per day may be as effective as a 10-day course in adults.10

Abruptly ceasing oral prednisolone after a short course appears to be equally effective as tapering over a longer period. Tapering the dose does not reduce the risk of suppression of adrenal function.811 The dose should be tapered if oral corticosteroids have been taken for more than 2 weeks.

Action plans for worsening asthma that include instructions for the use of oral corticosteroids as well as instructions to increase the dose of inhaled corticosteroid, are effective in improving lung function and reducing hospital admissions.13

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Systemic corticosteroids in acute asthma

Systemic corticosteroids given within 1 hour of presentation to an emergency department reduce the need for hospital admission in patients with acute asthma, particularly if they have severe asthma or are not already taking systemic corticosteroids.14

Oral prednisolone is as effective as intravenous or intramuscular corticosteroids during acute asthma in adults.151617 Doses of up to 80 mg/day methylprednisolone (or up to 400 mg/day hydrocortisone) are adequate. Higher doses do not appear to be more effective in adults with acute asthma.18

After an acute asthma episode, a short course of systemic corticosteroids reduces the risk of relapse, hospitalisations, and use of short-acting beta2-agonist, and appears to be well tolerated.12 Oral and intramuscular corticosteroids are both effective.12

A course of 5–10 days is sufficient.891011 In adults, a 5-day course of prednisolone 40 mg per day may be as effective as a 10-day course.10 In children, a 3-day course is generally effective, but 5 days may be needed for children with severe or life-threatening acute asthma.4 The majority of studies have used 2mg/kg of oral prednisolone (maximum 60 mg) given initially then 1mg/kg per day.

Abruptly ceasing a short (less than 2 weeks) course of oral prednisolone appears to be equally effective as tapering the dose, and does not suppress adrenal function.811

Note: The recommendation in this Handbook for a maximum prednisolone dose of 50 mg for children is based on practical considerations, taking into account commercially available doses and strengths and consistency with the dose recommended for adults.

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Systemic corticosteroids in acute asthma: adverse effects

Short-term use of oral corticosteroids is unlikely to cause harm – the majority of adverse effects are due to long-term high-dose use.19  Adverse effects associated with prednisone or prednisolone use include headache, nausea, vomiting, increased appetite, diarrhoea or constipation, vertigo, restlessness, insomnia and increased activity, salt and water retention, and increased blood pressure. High doses can be associated with behavioural changes, facial plethora, bruising and increased sweating.19

In people with diabetes or impaired glucose tolerance, corticosteroids increase blood glucose levels. Impaired glucose tolerance is common among people aged over 65 years. In patients with diabetes or impaired glucose tolerance, blood glucose monitoring (e.g. morning and evening samples) may be indicated during treatment with oral corticosteroids.

Long-term use of oral corticosteroids increases the risk of cataracts and osteoporosis in older patients,20 and may increase body weight.

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Systemic corticosteroids: psychiatric effects

Systemic corticosteroids can have a range of psychological effects. Large doses of prednisone or prednisolone can cause mood and behavioural changes, including nervousness, euphoria or mood swings, psychotic episodes including manic or depressive states, paranoid states and acute toxic psychoses.19 These adverse effects can occur in people without a previous history of psychiatric illness.19

Systemic corticosteroid treatment has been associated with elevated mood and reduction in depression among patients with asthma.2122 With long-term prednisone or prednisolone therapy, initial mood changes appear to stabilise over time.23

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Systemic corticosteroids and breast milk

Peak plasma level of systemic corticosteroid occurs at approximately 2 hours post dose, so peak milk level will also occur around this time. Therefore, the infant’s exposure to corticosteroids in breast milk can be further reduced by breastfeeding the infant just before each daily dose and avoiding feeding again until at least 4 hours after the dose.24, 25

If high-dose corticosteroids need to be used for longer than 10 days, the infant should be monitored for growth and development.2425

The US National Library of Medicine’s Drugs and Lactation Database (LactMed) states that: limited information indicates that maternal doses of prednisolone up to 50 mg produce low levels in milk and would not be expected to cause any adverse effects in breastfed infants. With high maternal doses, avoiding breastfeeding for 4 hours after a dose should markedly decrease the dose received by the infant. However, this [manoeuvre] is probably not necessary in most cases.

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References

  1. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from: http://erj.ersjournals.com/content/32/4/1096.full
  2. Oommen A, Lambert PC, Grigg J. Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial. Lancet. 2003; 362: 1433-1438. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)14685-5/fulltext
  3. Panickar J, Lakhanpaul M, Lambert PC, et al. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med. 2009; 360: 329-328. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa0804897#t=article
  4. van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: http://www.thoracic.org.au/clinical-documents/area?command=record&id=14
  5. Vuillermin P, South M, Robertson C. Parent-initiated oral corticosteroid therapy for intermittent wheezing illnesses in children. Cochrane Database Syst Rev. 2006; Issue 3: CD005311. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005311.pub2/full
  6. Vuillermin P, Robertson CF, Carlin JB, et al. Parent initiated prednisolone for acute asthma in children of school age: randomised controlled crossover trial. BMJ. 2010; 340: c843. Available from: http://www.bmj.com/content/340/bmj.c843.long
  7. Beigelman A, King TS, Mauger D, et al. Do oral corticosteroids reduce the severity of acute lower respiratory tract illnesses in preschool children with recurrent wheezing?. J Allergy Clin Immunol. 2013; 131: 1518-1525. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23498594
  8. Cydulka RK, Emerman CL. A pilot study of steroid therapy after emergency department treatment of acute asthma: is a taper needed?. J Emerg Med. 1998; 16: 15-19. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9472754
  9. Hasegawa T, Ishihara K, Takakura S, et al. Duration of systemic corticosteroids in the treatment of asthma exacerbation; a randomized study. Intern Med. 2000; 39: 794-797. Available from: https://www.jstage.jst.go.jp/article/internalmedicine1992/39/10/3910794/_article
  10. Jones AM, Munavvar M, Vail A, et al. Prospective, placebo-controlled trial of 5 vs 10 days of oral prednisolone in acute adult asthma. Respir Med. 2002; 96: 950-954. Available from: http://www.resmedjournal.com/article/S0954-6111(02)91369-7/abstract
  11. O'Driscoll BR, Kalra S, Wilson M, et al. Double-blind trial of steroid tapering in acute asthma. Lancet. 1993; 341: 324-327. Available from: http://www.sciencedirect.com/science/article/pii/0140673693901343
  12. Rowe BH, Spooner C, Ducharme F, et al. Corticosteroids for preventing relapse following acute exacerbations of asthma. Cochrane Database Syst Rev. 2007; Issue 3: CD000195. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000195.pub2/full
  13. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax. 2004; 59: 94-99. Available from: http://thorax.bmj.com/content/59/2/94.full
  14. Rowe BH, Spooner C, Ducharme F, et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001; Issue 1: CD002178. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002178/full
  15. Clark S, Costantino T, Rudnitsky G, Camargo CA. Observational study of intravenous versus oral corticosteroids for acute asthma: an example of confounding by severity. Acad Emerg Med. 2005; 12: 439-435. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15860696
  16. Cunnington D, Smith N, Steed K, et al. Oral versus intravenous corticosteroids in adults hospitalised with acute asthma. Pulm Pharmacol Ther. 2005; 18: 207-12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15707855
  17. Razi E, Moosavi GA. A comparative efficacy of oral prednisone with intramuscular triamcinolone in acute exacerbation of asthma. Iran J Allergy Asthma Immunol. 2006; 5: 17-22. Available from: http://ijaai.tums.ac.ir/index.php/ijaai/article/view/127
  18. Manser R, Reid D, Abramson MJ. Corticosteroids for acute severe asthma in hospitalised patients. Cochrane Database Syst Rev. 2001; Issue 1: CD001740. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001740/full
  19. Aspen Pharmacare Australia Pty Ltd. Product information: Panafcort (prednisone) and Panafcortelone (prednisolone). Therapeutic Goods Administration, Canberra, 2010. Available from: https://www.ebs.tga.gov.au
  20. Edmonds ML, Milan SJ, Camargo CA, et al. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev. 2012; 12: CD002308. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002308.pub2/full
  21. Brown ES, Suppes T, Khan DA, Carmody TJ. Mood changes during prednisone bursts in outpatients with asthma. J Clin Psychopharmacol. 2002; 22: 55-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11799343
  22. Brown ES, Denniston D, Gabrielson B, et al. Randomized, double-blind, placebo-controlled trial of acetaminophen for preventing mood and memory effects of prednisone bursts. Allergy Asthma Proc. 2010; 31: 331-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20819324
  23. Brown ES, Vera E, Frol AB, et al. Effects of chronic prednisone therapy on mood and memory. J Affect Disord. 2007; 99: 279-83. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1852520/
  24. Briggs G, Freeman R, Yaffe S. Drugs in Pregnancy and Lactation – A Reference Guide to Fetal and Neonatal Risk. Lippincott, Williams & Wilkins, Philadelphia, 2008.
  25. Hale T. Medications and Mothers’ Milk: Manual of Lactational Pharmacology. 14th edn. Hale Publishing, Amarillo, 2010.