Asthma Management Handbook

Starting systemic corticosteroid treatment

Recommendations

For adults, start systemic corticosteroids within 1 hour of presentation (unless contraindicated), regardless of severity at initial assessment.

Give starting dose of prednisolone 37.5–50 mg, then repeat each morning on second and subsequent days (total 5–10 days).

It is usually not necessary to taper the dose unless the duration of treatment exceeds 2 weeks.

Note: Pregnancy is not a contraindication for systemic corticosteroids. Oral prednisone or prednisolone is rated category A for pregnancy.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Cydulka and Emerman, 19981
  • Dembla et al. 20112
  • Hasegawa et al. 20003
  • Hatton et al. 20054
  • Jones et al. 20025
  • Karan et al. 20026
  • Kravitz et al. 20117
  • Manser et al. 20018
  • O'Driscoll et al.19939
  • Rowe et al. 200110
  • Rowe et al. 200711

For children aged 6 years and over (and children aged 0–5 if acute wheezing is severe), start systemic corticosteroids within 1 hour of presentation (unless contraindicated).

Give prednisolone as a single starting dose of 2 mg/kg (maximum 50 mg) orally, then 1 mg/kg each morning for 2 days (total 3 days). A longer course (e.g. 5 days) may be needed for severe cases.

It is usually not necessary to taper the dose unless the duration of treatment exceeds 2 weeks.

  • For children aged 0–5 years, systemic corticosteroids should generally be limited to those with severe acute wheezing to avoid over-use (particularly for those with intermittent viral-induced wheezing).
How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Van Asperen et al. 201012

For adults, if corticosteroids cannot be given orally, give intravenously.

Give up to 100 mg hydrocortisone IV every 6 hours.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Chan et al. 200113
  • Clark et al. 200514
  • Cunnington et al. 200515
  • Dembla et al. 20112
  • Kravitz et al. 20117
  • Lahn et al. 200416
  • Razi and Moosavi, 200617

For children, if corticosteroids cannot be given orally, give intravenously.

Give either of the following:

  • hydrocortisone IV initial dose 8–10 mg/kg (maximum 300 mg), and then 4–5 mg/kg (maximum 300 mg) every 6 hours on day 1, every 12 hours on day 2, once daily on day 3 and, if needed, once daily on days 4–5
  • methylprednisolone IV initial dose 2 mg/kg (maximum 60 mg), and then 1 mg/kg (maximum 60 mg) every 6 hours on day 1, every 12 hours on day 2, once daily on day 3 and, if needed, once daily on days 4–5.
How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Van Asperen et al. 201012

Do not use inhaled corticosteroids as a substitute for systemic corticosteroids.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Edmonds et al. 201218
  • Upham et al. 201119

More information

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.10

Oral prednisolone is as effective as intravenous or intramuscular corticosteroids during acute asthma in adults.141517 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.8

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.11 Oral and intramuscular corticosteroids are both effective.11

A course of 5–10 days is sufficient.1359 In adults, a 5-day course of prednisolone 40 mg per day may be as effective as a 10-day course.5 In children, a 3-day course is generally effective, but 5 days may be needed for children with severe or life-threatening acute asthma.12 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.19

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.20  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.20

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,18 and may increase body weight.

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Inhaled corticosteroids in acute asthma

Inhaled corticosteroid treatment in acute care

Clinical trial evidence does not support the use of inhaled corticosteroids in place of systemic corticosteroid treatment in the treatment of acute asthma.18

Some randomised clinical trials suggest that inhaled corticosteroid treatment may reduce hospital admission rates when given in addition to systemic corticosteroids, but the evidence is conflicting.18 Overall, evidence from randomised clinical trials does not show that inhaled corticosteroid therapy achieves clinically important improvement in lung function or clinical scores when used in acute asthma in addition to systemic corticosteroids.18

Inhaled corticosteroid treatment in post-acute care

Current standard follow-up treatment after acute asthma includes a course of systemic corticosteroids, and continuation of inhaled corticosteroids for patients already taking this treatment.

Overall, evidence from randomised clinical trials suggests that inhaled corticosteroid treatment, given at discharge from the emergency department after acute asthma, does not provide additional short-term benefit in patients who are also receiving oral corticosteroids.21

Some randomised clinical trials suggest that high-dose inhaled corticosteroid treatment at discharge from the emergency department may be as effective as oral corticosteroids in patients with mild acute asthma, but overall evidence does not support replacing oral corticosteroids with inhaled corticosteroids.21

These clinical trials were designed to assess effects of inhaled corticosteroid in managing the current acute asthma episode. This evidence does not suggest that inhaled corticosteroids should be stopped after or during an acute asthma episode.21 Regular inhaled corticosteroid treatment is effective for preventing future flare-ups.22

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References

  1. 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
  2. Dembla G, Mundle RP, Salkar HR, Doifoide DV. Oral versus intravenous steroids in acute exacerbation of asthma--randomized controlled study. J Assoc Physicians India. 2011; 59: 621-623. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22479740
  3. 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
  4. Hatton MQ, Vathenen AS, Allen MJ, et al. A comparison of 'abruptly stopping' with 'tailing off' oral corticosteroids in acute asthma. Respir Med. 1995; 89: 101-104. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7708993
  5. 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
  6. Karan RS, Pandhi P, Behera D, et al. A comparison of non-tapering vs. tapering prednisolone in acute exacerbation of asthma involving use of the low-dose ACTH test. Int J Clin Pharmacol Ther. 2002; 40: 256-262. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12078939
  7. Kravitz J, Dominici P, Ufberg J, et al. Two days of dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a randomized controlled trial. Ann Emerg Med. 2011; 58: 200-204. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21334098
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. Chan JS, Cowie RL, Lazarenko GC, et al. Comparison of intramuscular betamethasone and oral prednisone in the prevention of relapse of acute asthma. Can Respir J. 2001; 8: 147-152. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11420590
  14. 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
  15. 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
  16. Lahn M, Bijur P, Gallagher EJ. Randomized clinical trial of intramuscular vs oral methylprednisolone in the treatment of asthma exacerbations following discharge from an emergency department. Chest. 2004; 126: 362-368. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1082734
  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. 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
  19. Upham BD, Mollen CJ, Scarfone RJ, et al. Nebulized budesonide added to standard pediatric emergency department treatment of acute asthma: a randomized, double-blind trial. Acad Emerg Med. 2011; 18: 665-673. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21762229
  20. 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
  21. Edmonds ML, Milan SJ, Brenner BE, et al. Inhaled steroids for acute asthma following emergency department discharge. Cochrane Database Syst Rev. 2012; 12: CD002316. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002316.pub2/full
  22. Pauwels RA, Pedersen S, Busse WW, et al. Early intervention with budesonide in mild persistent asthma: a randomised, double-blind trial. Lancet. 2003; 361: 1071-1076. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12672309