Asthma Management Handbook

Starting systemic corticosteroid treatment

Recommendations

For adults with acute asthma, 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. Acute asthma in pregnancy should be treated immediately on presentation, to minimise risk to the foetus and to the woman.

How this recommendation was developed

Evidence-based recommendation

Based on literature search and formulated by multidisciplinary working group.

Key evidence considered:

  • Rowe et al. 20171
  • Normansell et al. 20162
  • Rowe et al. 20073
  • Cunnington et al. 20054
  • Rowe et al. 20015
  • Manser et al. 20016

Last reviewed version 2.0

 

For children aged 6-11 years with acute asthma (and children aged 1–5 if acute wheezing is severe), start systemic corticosteroids within 1 hour of presentation (unless contraindicated).

Give prednisolone 1 mg/kg (maximum 50 mg) orally each morning for 3 days.

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

Note: A longer course (e.g. 5 days) may be needed for severe cases.

  • For children aged 1-5 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

Evidence-based recommendation

Based on literature search and formulated by multidisciplinary working group.

Key evidence considered:

  • Foster et al. 20187
  • Castro-Rodrioguez et al. 20168
  • van Asperen et al 20109
  • Panickar et al. 200910
  • Chang et al. 200811
  • Smith et al. 200312
  • Rowe et al. 20015

Last reviewed version 2.0

Oral dexamethasone (if available) can be used as an alternative to prednisolone.

Children: 0.6 mg/kg as a single dose (can be repeated on the following day if needed)

Adults: 16 mg for 2 days then cease.

  • Do not exceed 2 days of treatment
How this recommendation was developed

Evidence-based recommendation

Based on literature search and formulated by multidisciplinary working group.

Key evidence considered:

  • Rehrer et al 201613
  • Walia 201814
  • Bravo-Soto et al. 201715
  • Meyer et al. 201416
  • Keeney et al. 201417
  • Paniagua et al. 201718
  • Cronin et al. 201619, 20
  • Kravitz et al. 201121
  • Gordon et al. 200722
  • Qureshi et al. 200123

Last reviewed version 2.0

For adults, if corticosteroids cannot be given orally, give IV hydrocortisone 4 mg/kg (maximum 100 mg) every 6 hours for 24 hours then reduce over next 24 hours or switch to oral prednisolone.

How this recommendation was developed

Evidence-based recommendation

Based on literature search and formulated by multidisciplinary working group.

Key evidence considered:

  • Cunnington et al. 20054
  • Rowe et al. 20015
  • Manser et al. 20016

Last reviewed version 2.0

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

Give either of the following:

  • hydrocortisone IV 4 mg/kg (maximum 100 mg) every 6 hours on day 1 then reduce (every 12 hours on day 2, once daily on day 3 and, if needed, once daily on days 4–5) or switch to oral prednisolone
  • methylprednisolone IV 1 mg/kg (maximum 60 mg) every 6 hours on day 1 then reduce (every 12 hours on day 2, once daily on day 3 and, if needed, once daily on days 4–5) or switch to oral prednisolone.
  • For children aged 1-5 years, systemic corticosteroids should generally be limited to those with severe acute wheezing.

 

How this recommendation was developed

Evidence-based recommendation

Based on literature search and formulated by multidisciplinary working group.

Key evidence considered:

  • Rowe et al. 20015
  • Smith et al. 200312
  • Gleeson et al. 199024
  • Becker et al. 199925
  • Barnett et al. 199726

Last reviewed version 2.0

Do not use inhaled corticosteroids as a substitute for systemic corticosteroids in adults or children.

Note: Patients taking inhaled corticosteroids should continue taking them as usual during oral corticosteroid treatment.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to named source(s):

  • Edmonds et al. 201227

Last reviewed version 2.0

More information

Systemic corticosteroids in acute asthma

Systemic corticosteroids in acute asthma

In adults and school-aged children with acute asthma, systemic corticosteroids given within 1 hour of presentation to an emergency department reduce the need for hospital admission.5 In children admitted to hospital with acute asthma, systemic corticosteroid treatment may achieve earlier discharge and fewer relapses.12

In preschool children with acute viral-induced wheezing, there is inconsistent evidence for the benefits of systemic corticosteroids.7, 10, 28 Oral corticosteroids may be beneficial in children younger than 6 years with frequent acute wheezing or asthma, but current evidence does not strongly support their use in this age group.8 The Thoracic Society of Australia and New Zealand position statement on the use of corticosteroids in children9 recommends that the use of systemic corticosteroids in preschool children, particularly those with intermittent viral induced wheezing, should be limited to those with wheeze severe enough to need admission to hospital.

After an acute asthma episode, treatment with systemic corticosteroids (intramuscular corticosteroids, oral prednisone/prednisolone, or oral dexamethasone) at discharge from the emergency department reduces the risk of relapse in adults1 and children.29, 30

Formulation and route of administration

In adults and children with acute asthma, oral prednisone/prednisolone is as effective as intravenous or intramuscular corticosteroids.5, 2

Oral dexamethasone is as effective as prednisone/prednisolone in adults and children13, 14, 15, 16, 17, 19, 20, 3, 21

Dose

In adults, 40 mg per day prednisolone/prednisone,31  up to 80 mg/day methylprednisolone, or up to 400 mg/day hydrocortisone6 are adequate.

In children the majority of studies in children have used 1–2 mg/kg of oral prednisolone (maximum 60 mg) given initially then 1 mg/kg per day. Current evidence does not support the use of higher doses.2

Studies evaluating oral dexamethasone in adults have used a single dose of 12 mg13 or 16 mg on 2 consecutive days.21 Most studies evaluating oral dexamethasone in children have used 0.6 mg/kg per dose on one or two consecutive days.16

Duration

In adults, an oral or intramuscular corticosteroid course of at least 7 days appears more effective than a shorter course in preventing relapse within 10 days of discharge after acute asthma,1 although one clinical trial evaluating prednisone reported that 5 days was as effective as 10 days.32 Courses less than 5 days are not recommended.

In children, a 3-day course of prednisone/prednisolone is generally as effective as a 5-day course,11 but 5 days may be needed for children with severe or life-threatening acute asthma.9

It is not necessary to taper the dose after a short course of oral prednisone/prednisolone.1, 33, 34

Dexamethasone has a longer half-life than prednisone/prednisolone. Longer courses may more pronounced mineralocorticoid adverse effects. Oral dexamethasone treatment in adults or children should not exceed 2 days.

Adverse effects

Short-term use of oral corticosteroids to treat acute asthma is often well tolerated in children and adults,5, 12, 10, 3 but many patients report significant adverse effects, particularly mood changes, gastrointestinal disturbances,36 nocturia, and difficulty sleeping. While short courses of high-dose systemic treatment cause fewer adverse effects than prolonged courses of lower doses,37 more recent analyses have shown a significant association between short courses of oral corticosteroids and sepsis, thromboembolism and fracture.38, 39

Oral dexamethasone appears to be well tolerated in adults.13 In children it may be associated with less vomiting than prednisone/prednisolone.14, 15, 16, 17, 17, 19, 20 The risk of unwanted mineralocorticoid effects are increased if dexamethasone is taken for more than 2 days.

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.

Last reviewed version 2.0

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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.40

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.40 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.40

Inhaled corticosteroid treatment in post-acute care - short term effects

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 short term 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.41

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.41

These clinical trials were designed to assess short term 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.41 Regular inhaled corticosteroid treatment is highly effective for preventing asthma flare-ups, including in patients with a recent asthma hospitalisation. A large case-control study showed that, after hospitalisation for asthma, regular ICS were associated with a 39% reduction in the risk of re-hospitalisation within the following 12 months.

Rationale for prescribing inhaled corticosteroids at discharge from acute care

Inhaled corticosteroid treatment reduces the frequency and severity of asthma flare-ups, reduces the risk of asthma hospitalisation and rehospitalisation, and reduces the risk of death due to asthma.42, 43

Regular inhaled corticosteroid treatment is therefore indicated for all adults and older adolescents who have experienced a flare-up within the last 12 months, as well as for those with asthma that is not well controlled (asthma symptoms twice or more during the past month, or waking due to asthma symptoms once or more during the past month).

At the time of discharge from the emergency department or hospital, there is an opportunity to start inhaled corticosteroid treatment and to ensure that the patient's usual GP will review the treatment regiment at the follow-up visit.

Last reviewed version 2.0

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References

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  2. Normansell R, Kew KM, Mansour G. Different oral corticosteroid regimens for acute asthma. Cochrane Database Syst Rev 2016; Issue 5: CD011801. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27176676/
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