Prednisone Dose For Asthma Exacerbation

Overview

Asthma is a condition that causes airways to swell, become inflamed, narrow and fill with mucus. This is usually caused by triggers in the environment such as dust, house mites, pollen, cigarette smoke and animal fur amongst other things. Although some asthma attacks can be unpredictable. The swelling, inflammation and narrowing of the airways can be reversed using prednisone, an oral steroid medication (also called corticosteroid). It can help to reduce the severity of an attack and be a life saving treatment by suppressing the immune response to triggers.

Steroids are usually given to someone having an acute asthma attack as tablets, although they can be administered through an inhaler or an injection. Prednisone is used as a short term treatment for acute asthma that becomes exacerbated or there is an increased likelihood or seriousness of an attack that cannot be treated with an inhaler. The dosages are lower for outpatients and are typically given as a short burst of medication lasting between 5-7 days and from 5mg to 50mg per day taken in the morning (as they may make it difficult to sleep otherwise). This should help to bring asthma under control so that inhalers may be used again as normal practice. 

It can also be used as a long term treatment if inhalers or other medications are unsuccessful in controlling the condition but as steroids like prednisone can have side effects it is unlikely to be the first option. In some cases, it can be administered intravenously if the attack is severe enough to require hospital admission. The dosage then is often higher and can range from 60-100mg per day.

What is an asthma exacerbation?

Causes

Asthma exacerbation is also commonly known as an asthma attack. The word exacerbation means when an existing situation or condition becomes worse. Asthma is often a life long condition that many people have to learn to live with. There are a variety of environmental causes of asthma aggravation or attack, which are commonly referred to as ‘triggers’. To ensure asthma is not exacerbated it is important to identify and then avoid these triggers wherever possible.

What triggers an asthma attack is often specific to each individual. One person may find that exposure to animal fur can cause an exacerbation of their symptoms whilst for another, there is little or no reaction. It is important for each individual to identify what specific triggers there are for their condition if they want to keep it under control. However, there are some common triggers that many asthmatics will typically have a reaction to. These can include things like:

• Dust mites
• Animal fur and feathers
• Cigarette smoke
• Cold air
• Mold
• Traffic and factory fumes
• Spray deodorants and strong perfumes
• Plants
• Pollen
• Some medications
• Disinfectants and other cleaning products
• Paint fumes
• Colds and flu or other infections
• Air con and cold, winter air
• Stress
• Laughter

Even though this is quite a comprehensive list, there may still be something specific, not included here, that can cause an attack. 

Asthma is what is described as an ‘atopic’ condition. It is another word for allergies caused by the immune system having an over reactive response causing the individual to be allergic to things that are often harmless to most people. Atopic conditions are thought to be genetic, often running in families so the risk of having asthma increases if a family member has it or other atopic conditions (such as eczema or coeliac disease for example). Other things that can increase the risk are premature birth (as lungs may not have strengthened sufficiently), prenatal smoking or being exposed to smoke during infancy and childhood, being exposed to pollutants (through employment for example,) or if the respiratory system is damaged due to an infection.

The over reactive response of the immune system causes the airways of the lungs to become overly sensitive to the triggers leading them to constrict (become narrower), become inflamed and fill with mucus. This causes a range of uncomfortable symptoms to develop.

Symptoms

Symptoms typically experienced can include:

• Breathlessness
• A whistling sound when breathing called wheezing
• Chest pain
• Shoulder pain
• Back pain
• Coughing

When the asthma is exacerbated so that it is acute (an asthma attack) other symptoms can include:

• The chest feels tight
• Difficult breathing
• Increase in heart rate and breathing rate
• Feeling dizzy or drowsy
• Losing consciousness
• Blue lips and fingernails

Prednisone for asthma treatment

How effective is Prednisone for asthma treatment?

According to research in the National Library of Medicine¹ on the use of corticosteroids in the treatment of acute asthma, they were first used in 1956 with positive outcomes. This led to the further development of corticosteroids with the aim to reduce their mineralocorticoid activity which affects fluid balance as they cause the kidneys to reabsorb too much sodium and can cause fluid retention and high blood pressure (hypertension). 

Prednisone has proven to be effective in treating asthma exacerbation but also has low mineralocorticoid activity and so has become a widely used treatment. Later, scientists developed a corticosteroid called dexamethasone which has no mineralocorticoid activity but is much more potent than prednisone (6mg of prednisone is about the equivalent of 1mg of dexamethasone) and is longer lasting. A review (umbrella study) of many other studies carried out by Krishan et al² (2009) found that the evidence in each case found prednisone was effective but also that higher doses than the standard dose do not prove beneficial. Also, with increased potency comes the possibility of increased side effects and difficulty in weaning off the drug, thereforeprednisone (which is also cheaper to produce) is often considered to be the most effective treatment.

Route of administration

Prednisone can be administered for asthma in several different ways:

• In tablet form (this is the most common method)
• Oral solution
• Inhaled using an inhaler
• Nasal sprays (can help with allergies that may trigger an exacerbation of symptoms)
• Injection
• Intravenously (in hospital for serious exacerbation)

Prednisone dosage

 Prednisone is a copy of a hormone (corticosteroid) that is made naturally by the body and mimics its function. It is important not to abruptly stop prednisone because it can take the body a while to readjust its natural corticosterone levels which can cause withdrawal symptoms. These symptoms can be very unpleasant and include things like vomiting, headaches, and weight loss and if heavy doses have been administered then withdrawal can cause a crisis for the adrenal glands which can be potentially fatal. Therefore, It is very important to taper off prednisone slowly to enable the adrenal glands to begin to make normal levels of the steroid.  

The prescribed dose for prednisone will depend on the level of exacerbation of asthma for each individual. A high dose would generally be anything above 40 mg per day. Often each tablet is 5mg and one or two of these per day (taken at the same time) would be considered a low dose.

So generally anything between 10 mg - 40 mg per day would be considered a normal dosage. 

Taking a preventer inhaler everyday as instructed can help to reduce the likelihood that asthma will become exacerbated and therefore the need for prednisone or other corticosteroids. 

Prednisone is not considered to be safe to use during pregnancy or breastfeeding.

Dose interval

Prednisone is usually taken once a day in the morning after breakfast (as they can cause restlessness and interfere with sleep or cause sickness on an empty stomach). They are usually taken for a period of 5-7 days (for adults and 3 days for children) or until the exacerbated asthma symptoms subside.

Sometimes if an inhaler is not effective enough to improve the inflammation and other symptoms of asthma, prednisone may be prescribed for a longer period of time.

What prednisone is used for?

Prednisone has proven to be effective in treating asthma exacerbation since it was first used in 1956. However, it is generally used for any atopic conditions (allergies or other symptoms caused by the hypersensitivity of the immune system). According to the National Library of Medicine, it was so successful in the treatment of arthritis in 1949 that the researcher Philip Showalter Hench won the Nobel prize the following year. It is used for a range of inflammatory conditions in fact and can be used to treat for example:

• Allergies
• Arthritis
• Eye problems 
• Adrenal problems
• Skin conditions
• Lupus
• Stomach or bowel problems

As for asthma prednisone can be used as a short term treatment or long term treatment for other atopic conditions. For example, it can be used to treat acute exacerbation of eczema or dermatitis or other allergic reactions. It can also be highly effective in reducing flare-ups in Crohn's disease and has been one of the main treatments for inflammatory bowel diseases since the 1950s.

Side effects of prednisone

The extent of the side effects of prednisone depend on the strength of the dose but as already discussed above, it can increase mineralocorticoid activity. This means the renal system retains sodium, causing fluid retention and high blood pressure or changes in heart rate due to reducing potassium levels. Prednisone is designed to suppress hypersensitivity of the immune system to prevent inflammation of the airways and because of this, the immune system is suppressed which may increase vulnerability to common infections.

Short term side effects can include:

• Headaches
• Dizziness
• Insomnia (difficulty sleeping)
• Feeling restless
• Increased sweating
• Indigestion
• Stomach upset

Longer term side effects can include:

• Weight gain
• Mood changes
• Muscle weakness and fatigue
• Changes in heart rate
• Swelling (in arms, legs, abdomen, pancreas)
• Puffiness in the face (called moon face), neck and upper back
• Bruising easily
• Loss of appetite
• Thinning of the bones (osteoarthritis) 
• Negative impact on diabetes
• Eyesight problems

Side effects can increase or become more severe if prednisone is taken with other medications as it interacts with them. This can include prescribed medication, vitamins, minerals or other substances. For example, it can interact with diabetes medication causing blood sugar levels to rise or it can make the blood thinning drug called warfarin less effective. As prednisone suppresses the immune system it is also important not to have any live vaccinations whilst taking it, as it could increase the risk of serious infection from the vaccine.

What can I do to stay healthy while taking Prednisone

The first thing to do to stay healthy while taking prednisone is, of course, to remove and avoid any potential triggers. Even if tobacco smoke doesn’t particularly trigger an attack, it is damaging to the lungs. So it is important not to smoke or ingest things that might.

Even though it's usually considered a positive thing to exercise as it can help to strengthen the lungs and improve general health, unfortunately for some, it can also be a trigger. However, with the correct medication and approach, exercise can still be carried out without triggering an attack. In fact, it is really important to ensure that people with asthma don’t give up exercise because it has a number of benefits for the lungs and can help with long term management of symptoms. Exercise increases heart rate and therefore increases the flow of oxygen not only to the heart and around the body but to the lungs themselves and reduces carbon dioxide levels. The capacity of the lungs will also increase, as well the stamina and respiratory muscles’ strength. One study by the British Medical Journal³ (2015) found that aerobic exercise helps to reduce the hyperresponsiveness of the bronchial airways and so they are less likely to become inflamed and therefore reduce other symptoms.

Another activity that can help asthmatics to stay healthy is exercise such as yoga which helps to slow down and focus breathing or other breathing exercises and techniques. There are a range of different techniques that have been evidenced by scientific research to have a positive impact on the control of asthma that may complement or reduce the need for medication. Having the right breathing technique is important because it helps to ensure the right balance of oxygen and carbon dioxide in the lungs and bloodstream. The Global Allergy and Airways Patient Platform⁴ discusses some of these techniques which include the Papworth Method⁵, (which focuses on slow breathing), diaphragmatic breathing (which helps to strengthen the diaphragm), Pursed Lip Breathing (breathing in through the nose and out through pursed lips) and Buteyko breathing (focuses on breathing through the nose).  

Other anti-inflammatory drugs for asthma treatment 

Prednisone is not usually used as an everyday treatment for asthma. They are usually used in addition to inhalers to manage the condition if asthma exacerbation has become severe. The usual course of medication for controlling asthma exacerbation is inhalers (inhaled glucocorticosteroids) which come in two forms called preventers and relievers. A preventer inhaler is used daily with the aim to reduce the sensitivity of the airways and prevent symptoms from occurring so that the condition can be controlled. However, a reliever is also usually prescribed which aims to relieve symptoms of short-term exacerbation and prevent it from becoming more serious. There are also combination inhalers that include the medication of both preventer and reliever for individuals who struggle to control their asthma as they provide long-lasting relief and prevention.  

The NHS⁶ also describes other types of anti-inflammatory drugs for asthma which include tablets (Leukotriene receptor antagonists and theophylline), injections (for some people with severe asthma), surgery (also for severe asthma) and other complementary therapies. As well as the breathing techniques already discussed, therapies can include dietary supplements and herbal remedies, acupuncture and ionisers. However, the NHS points out that there is insufficient scientific evidence to prove their effectiveness and there needs to be more research on these therapies. Some of these therapies may even have detrimental effects if taken with prednisone, as it may interact with it increasing the side effects or the severity of symptoms. Therefore, it's really important to speak to a GP before making use of them.

Summary

Evidence collected over a number of years and from a range of studies consistently demonstrates that prednisone can be effective for treating not only asthma exacerbation but also a range of other hypersensitive immune conditions. It is a powerful anti-inflammatory drug but side effects can be severe if not carefully prescribed as it can also interact with other medications. However, the benefits for many atopic conditions outweigh the risks. It can be administered in a range of different forms which makes it flexible and easy to administer making prednisone therapies an attractive treatment option for patients and healthcare providers.