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Prednisone Taper For Asthma Exacerbation

How Does Prednisone Treat Asthma

Prednisone for Asthma Exacerbations | What You Need to Know? – Chet Tharpe MD

Oral prednisone is a systemic anti-inflammatory steroid. That means that after taking prednisone by mouth , it is absorbed in the body, unlike inhaled steroids that go straight to the lungs. Prednisone decreases your immune system’s response to reduce symptoms such as swelling and allergic-type reactions.

Prednisone and other systemic steroids may be used to treat asthma attacks and help people gain better asthma control. Steroids are used with other asthma medications to either control sudden and severe asthma attacks or to treat long-term, hard-to-control asthma.

When Are Inhaled Steroids Used For Asthma

Anti-inflammatory asthma inhalers are often used as a first-line controller treatment for asthma. After introduction of inhaled steroids, the need for oral steroids such as prednisone may decrease.

Unlike the serious side effects of oral steroids, the most common side effects of anti-inflammatory asthma inhalers are hoarseness and thrush, especially in elderly adults. As with all asthma inhalers, you should rinse the mouth carefully after using your inhaler. Gargle with water after inhalation to help reduce the risk of oral thrush.

For more detail, see WebMDâs Asthma, Steroids & Other Anti-Inflammatory Drugs.

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How Much Will I Take

Prednisone is available as an oral tablet or oral liquid solution in the United States. While similar, prednisone isnt the same as methylprednisolone, which is available as an injectable solution as well as an oral tablet. Typically, oral prednisone is used as a first-line therapy for acute asthma because its both easier to take and less expensive.

The average length of prescription for corticosteroids such as prednisone is 5 to 10 days. In adults, a typical dosage rarely exceeds 80 mg. The more common maximum dose is 60 mg. Dosages greater than 50 to 100 mg per day arent shown to be more beneficial for relief.

If you miss a dose of prednisone, you should take the missed dose as soon as you remember. If its almost time for your next dose, skip the missed dose and take the next regularly scheduled dose.

You should never take an extra dose to make up for a dose that youve missed. In order to prevent an upset stomach, its best to take prednisone with food or milk.

Read Also: Best Inhaled Corticosteroid For Asthma

How Effective Is Prednisone For Asthma

A review article in American Journal of Medicine evaluated six different trials for adults with acute asthma episodes. In these trials, people received corticosteroid treatment within 90 minutes of arriving at the emergency room. Researchers found that these groups had lower hospital admittance rates than people who received a placebo instead.

Additionally, a review on management of acute asthma attacks in American Family Physician found that people sent home with a 5- to 10-day prescription of 50 to 100 milligrams of oral prednisone had a decreased risk of relapse of asthma symptoms. The same review states that in children 2 to 15 years old, three days of prednisone therapy at 1 mg per kilogram of body weight can be as effective as five days of prednisone therapy.

Side effects of prednisone can include:

  • fluid retention

Pathophysiology And Mechanisms Of Action Of Oral Corticosteroids In Asthma

Using Your Stethoscope &  Medical Devices for Treating Asthma

The anti-inflammatory nature of OCS is the key to their efficacy in asthma. At present, it is suspected that at least half of all patients with asthma have predominantly eosinophilic inflammation, including the majority with early onset disease associated with allergy.8 It is this population with eosinophilic inflammation that are the best understood and studied, especially with respect to the efficacy of corticosteroids. In these individuals, a complex interaction between genetics, airway damage and a maladaptive immune response within the airways leads to the development of asthma.9 Meanwhile, re-exposure to allergen, infection or other irritants initiates an inflammatory pathway mediated by cell signalling molecules, namely interleukins -4, 5 and 13. The term type 2 inflammation has been used to describe this eosinophilic pathway for inflammation in the patient with asthma, which is differentiated from non-type 2 inflammation, thought to be predominantly associated with neutrophilic or paucigranulocytic sputum phenotypes, and with potentially different pathobiological mechanisms. The inciting irritants and subsequent type 2 inflammatory cascade lead to recruitment of mast cells, eosinophils and CD4+ T lymphocytes and further release of their associated type 2 cytokines. The presence of this inflammation is associated with increased thickness of the smooth muscle layer, excessive and variable airway narrowing and increased secretion of mucus.10

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Biomarkers For Effective Ocs Dose Reduction

The use of biomarkers to monitor both the efficacy and safety of reducing OCS dose in these trials can support an individualized patient-focused approach. The OCS-sparing studies described here did not formally identify biomarkers to guide tapering, although serum cortisol concentration was used in the PONENTE study .

Blood eosinophil counts may also serve as useful indicators for effective OCS-tapering in patients with eosinophilic inflammation, as patients with OCS-dependent asthma may present with elevated levels of type 2 inflammatory markers . OCS-sparing studies have correlated elevated blood eosinophil counts to a loss of asthma disease control . Furthermore, an inverse association between OCS dose and blood eosinophil count has been demonstrated in patients with severe eosinophilic asthma not treated with an asthma biologic, with reduced OCS dose being associated with increased eosinophil count . Moreover, a post hoc analysis of data from SIRIUS showed that patients with the lowest blood eosinophil counts at baseline had the highest mean OCS dose at the end of the optimization phase . As such, timely blood eosinophil count might be useful as a potential biomarker for effective OCS dose reduction prior to biologic treatment initiation, either during OCS dose optimization in a trial setting or in real-world clinical practice.

Oral Corticosteroids For Asthma

Oral corticosteroids are taken in pill or liquid form. This medicine may be prescribed for the treatment of asthma attacks that dont respond to other asthma medicines. Corticosteroids are not the same as anabolic steroids taken by some athletes and banned in many athletic events. Oral corticosteroids are a common treatment for acute asthma flare-ups to reduce inflammation and swelling in the airways. OCS has been shown to reduce emergency room visits and hospitalizations for asthma. Some people with severe asthma use OCS as a long-term medicine, but OCS can have significant side effects and risks.

Short-term risks of OCS

A 2018 Asthma and Allergy Foundation of America survey of 519 patients with asthma found that nearly 85 percent used at least one course of OCS in the previous 12 months and 64 percent had done so two or more times. Patients who take two or more courses of OCS in a 12-month span may have severe or poorly controlled asthma and should speak with a qualified asthma specialist.

Recommended Reading: How Did Asthma Get Its Name

History Of Oral Corticosteroids Use In Asthma

Before the 1950s, the treatment for asthma was restricted to those compounds that were either plant-derived or adrenaline derivatives. This treatment consisted primarily of bronchodilator agents.4 With the development of steroid and adrenocorticotropic hormone extracts, a 1952 seminal study by McCombs noted the marked improvement that could be derived with respect to asthma symptoms and control using either corticosteroids or adrenocorticotropic hormone.5 It has since been determined that oral and parenteral corticosteroids have no significant difference in bioavailability, and thus oral corticosteroids are by far the most common formulation of systemic corticosteroid used in the treatment of asthma today. It was not until 1958 that the association between successful treatment with OCS and a reduction in eosinophils in the sputum was noted.6 This revelation opened the door to widespread treatment with OCS, both on a chronic and acute basis,4 but with this came increasing recognition of the side effects of systemic corticosteroids. The subsequent development of inhaled corticosteroids and the recognition that these can be equally as effective in the majority of patients with asthma, therefore, led to a decline in the use of OCS, except in the population with severe asthma.7

Steroids In Asthma: To Taper Or Not To Taper

Acute Asthma Exacerbation | USMLE Pulmonology | @BoardsMD

Steroids in Asthma: To Taper or Not to Taper?

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.

This is a small, carefully executed pilot study of patients treated in the emergency department for asthma exacerbation and judged suitable for discharge. No patients had concomitant respiratory disease and none had used steroids for two weeks prior to enrollment. Subjects were randomized to receive either an eight-day non-tapering course of prednisone 40 mg/d, or an eight-day tapering course of prednisone starting at 40 mg/d and reduced by 5 mg/d. All subjects had cortisol levels assayed and a cosyntropin stimulation test performed, both prior to receiving steroids and again 12 days after discharge. Fifteen subjects participated.

The tapering and non-tapering steroid groups demonstrated no differences in pulmonary function or rate of relapse during the 21-day study period. There was also no difference in plasma cortisol or response to cosyntropin stimulation test between the two groups. Cydulka and Emerman conclude that tapering of steroids does not result in clinical benefit and that a short course of steroids, with or without a taper, does not cause adrenal suppression.


1. O’Driscoll BR, et al. Double-blind trial of steroid tapering in acute asthma. Lancet 1993 341:324-327.

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Current Treatment Of Acute Asthma

Acute asthma exacerbations are defined as episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness, or some combination of these symptoms. Most recently, an expert group formed by the National Institutes of Health agreed to define acute asthma as a worsening of asthma requiring the use of systemic corticosteroids to prevent a serious outcome. Acute exacerbation of asthma symptoms is a common complication of the disease. The frequency in which exacerbations happen vary widely depending on the severity of disease, the degree of control with prophylactic medications, and exposure to triggers. In a multicenter study from the US, the admission rate of all comers to the emergency department with acute asthma was 23%. On the other hand, a European study showed that only about 7% of all patients with acute asthma exacerbation required hospitalization. We have a similar experience in Saudi Arabia where about 8% of all asthmatics with acute exacerbation are hospitalized, but if we look at only the severe group the rate goes up to 40%. These epidemiological data underscores the importance of effective treatment of asthma exacerbations and their prevention.

Long Term Use Of Oral Corticosteroids For Asthma

Current asthma guidelines recommend advancing asthma treatment in a step-wise fashion to reach disease control, for both improvement in symptoms and prevention of exacerbations.23 This step-wise progression begins with low dose inhaled corticosteroids, then, if necessary, it progresses to inhaled corticosteroids combined with long-acting -agonists, which will control most cases of asthma. Until recently, regular use of OCS was often the only effective option for those with severe disease that could not be controlled with the previous steps. Contemporary research has therefore focused on optimal dosing, and a Cochrane review has confirmed that OCS treatment that is titrated based on sputum eosinophil counts results in reductions in exacerbation rates compared with dosing based on clinical markers alone.24 The options have recently expanded and now include inhaled long-acting anticholinergic therapies and biological agents that directly target IgE and IL-5. Currently, the latter only have a role in patients who have severe allergic or eosinophilic asthma refractory to treatment with inhaled corticosteroids or long-acting -agonists, and can only be prescribed by specialists. When used appropriately, these biological agents are effective at reducing exacerbations and improving symptoms and control.25 In view of their more acceptable side effect profiles, they are often preferentially selected, when available, over the initiation or dose escalation of long term OCS.26

Read Also: Moderate To Severe Asthma Treatment

Assessing Asthma Control During Ocs

During tapering, OCS dose is reduced based on the level of asthma control, as well as symptoms of adrenal sufficiency . ACQ score, forced expiratory volume in 1 s measurements, morning peak expiratory flow measurements, occurrence/history of exacerbations, in addition to blood eosinophil counts, feature as indicators of asthma control across the five OCS tapering studies . Additionally, patients in SIRIUS used eDiaries to report their daily symptoms allowing close monitoring of asthma control by study investigators . The use of eDiaries has now become commonplace in subsequent studies . As such, methods to monitor asthma symptom control have broadened, from the sole reliance on clinical monitoring to a combination of clinical monitoring and patient-reported monitoring using standardized questionnaires . Such monitoring tools provide a much more holistic picture of asthma control throughout clinical studies.

Introduction And Evolution Of Corticosteroids In The Management Of Asthma: Historical Background

Prednisone taper order / Generic Meds

Shortly after the discovery of the structure of adrenal steroid hormones, Hench et al. examined using cortisone to treat arthritis in 1949. The effect was remarkable and that work won the Nobel Prize the next year. It also started a series of trials of corticosteroids in various inflammatory conditions. The first use of corticosteroid to treat acute asthma exacerbation was in 1956. Development of corticosteroids that have less mineralocorticoid activity, like prednisone, and later those that have no mineralocorticoid activity, like dexamethasone, made corticosteroids more attractive therapies to use in asthma. In 1972, Clark showed for the 1st time that inhaled beclomethasone was effective in the management of asthma with less adverse effects than systemic steroids. Numerous reports came afterwards describing the efficacy of oral prednisone and prednisolone , IV methylprednisolone and ICS such as triamcinolone, budesonide, and fluticasone in the management of asthma. These effects are mediated through various genomic and nongenomic mechanisms. Table 2 shows some common systemic corticosteroids and their relative potency.

Recommended Reading: Can Anxiety Cause Asthma Attack

Selecting An Oral Prednisolone Liquid For Children

Erika Giblin, PharmD Candidate 2015University of Florida, College of PharmacyGainesville, Florida

Professor, Pharmacotherapy and Translational ResearchProfessor of Pediatrics Gainesville, Florida

US Pharm

ABSTRACT: Asthma affects approximately one in 10 children in the United States. More than half of these pediatric patients experience an asthma exacerbation each year. Often, the exacerbation requires a short course of oral corticosteroids. Prednisolone, a liquid formulation of prednisone, is commonly prescribed to these children due to its ease of administration. A short course of prednisolone drastically reduces the need for hospitalization and shortens the length of the exacerbation. Poor adherence due to the bitterness or laxative qualities of prednisolone often limits its effectiveness, however, and careful selection must be made between the available forms .

Asthma is the most common cause of hospitalizations and emergency department visits for pediatric patients in the Unites States.1 These admissions are costly, cause missed school and work days, and utilize healthcare resources.2 Standard therapy with inhaled corticosteroids and short-acting bronchodilators will not prevent episodic viral-induced exacerbations in these patients.3

My Experience With Side Effects While Tapering Prednisone

The imbalance in the amount of cortisol our bodies produces is thought to contribute to the withdrawal symptoms and side effects that can be attributed to prednisone tapering. If I have to choose one of the side effects that I thought I was most greatly affected by. It would be the fogginess of my brain otherwise known as my reduced concentration. It makes trying to get work done, very difficult. There is also the crazy joint pain. These are just a few of the symptoms that may be encountered. The good news is that they are fairly short in duration and seem to mostly resolved when your adrenal glands take over. Of course, this will differ, if you are like me on a maintenance dose of prednisone, you may still encounter other side effect from your maintenance dose.

I have had a range of experiences with prednisone tapering if I am on high doses following an exacerbation. I can generally decrease down to 15mg or even 12.5mg, fairly easily without too many unwanted side effects. In my experience, I have had to taper more slowly to get down to a maintenance dose. In many circumstances, an asthmatic patient will be completely tapered off of it. If you have tapered off of steroids or decreased to a maintenance dose, you may also know what your threshold is or how you need to adjust your tapering schedule to decrease the side effects.

Also Check: Can Asthma Show On Chest X Ray

What Major Directions For Research Should Be Pursued

Large-scale, multi-center trials of corticosteroid use are needed to provide a more definitive evidence base for the management of acute asthma studies in patients with respiratory failure are urgently needed. In addition, there is emerging evidence that leukotriene modifiers , when initiated in the emergency department during acute asthma, may rapidly improve lung function and reduce the risk of relapse after emergency department discharge.53,54 A recent randomized clinical trial failed to show a benefit for improving relapse rates when LABAs were added to inhaled and systemic corticosteroids at the time of discharge from the emergency department .55 Thus, further large, multi-center clinical trials are needed to clarify the incremental benefit of combining corticosteroids with other agents during acute asthma.

Limited evidence exists in chronic asthma that treatment strategies that incorporate decisions to suppress eosinophilic airway inflammation provide better control of asthma and fewer episodes of acute asthma compared to treatment decisions based on assessment of symptoms and lung function alone.56, 57 While potentially appealing, given the cost and availability of these tests, further research is needed to evaluate the clinical benefit of incorporating biomarkers of eosinophilic airway inflammation in the acute care setting.58,59


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