What
may have struck you … as it does us … is that no one seems to know the exactly
“right” way to prescribe a steroid “burst.”
Sometimes you are given 40 mg of prednisone to start, sometimes 60 mg. If you went to the Emergency Department to
receive your first dose, it may have been given intravenously at twice the
amount, as methylprednisolone (Solu-Medrol) 125 mg. After the first dose you may have been given 5
days of treatment, 14 days, or longer.
And the dose may have been reduced from its initial large amount to zero
in various ways – by 10 mg/day every day or every two days, by 20 mg every 4
days, by inclusion of the low dose of 5 mg/day or not, etc. Or perhaps your doctor likes the Medrol dose-pack,
a pre-programmed 6-day tapering schedule in a package of tablets clearly laid
out with each day’s decreasing dose. And
most recently you may have been sent home with 50 mg/day for 5 days, then
stop. No taper to off, just stop
As you might surmise, such a variety of approaches
reflects lack of scientific knowledge.
The best way to prescribe a short course of oral steroids has not been
carefully studied in scientific trials, and it may be that there is no one
“right way” to use steroids. Some people
and some exacerbations of asthma may require more medicine for longer periods
of time, others may do well with less medicine for shorter duration. A recent experiment among more than 300 people with chronic obstructive pulmonary disease (COPD, the chronic
obstructive lung disease of cigarette smokers) found that 5 days of prednisone
at 40 mg/day was as effective as a two-week course of treatment [Leuppi, et al., Journal of the American Medical Association 2013; 309:2223-31], but
COPD is not asthma. It is uncertain
whether the same outcome would hold true among persons experiencing flare-ups of their
asthma.
What we do know may surprise you. Despite the time-honored approach of reducing
the dose of prednisone in stepwise decreases – the “steroid taper” -- research
has shown that abrupt discontinuation of oral steroids achieves the same asthma
control and prevention of recurrences as a slow steroid taper, as long as after the oral steroids you
continue preventive treatment with inhaled steroids. When used for a brief period (fewer than
2-3 weeks), there is no medical reason that the dose of oral steroids has to be
slowly decreased. It is o.k. to reduce
the dose in stepwise fashion, but it is not necessary for biologic reasons.
In the absence of scientific data, we are free to
share with you what we think is a reasonable general approach, acknowledging
that other recommendations may someday be found to be just as good or even
better (in which case we will change our approach!). During a severe asthma flare-up we begin
with prednisone between 40 and 60 mg/day (40 mg/day for smaller people, 60
mg/day for larger people). The tablets can be taken altogether in a single, once-a-day dose. It then makes
most sense to continue treatment at this dose until you are all better or
almost all better (as guided by your symptoms or, even better, by finding that
your measured peak flow has returned back to its usual value when you are
well), and then stop the prednisone or quickly reduce the dose to zero over a
few days. Typically, your medical
provider will make a guess as to how long it will take for you to recover from
your asthma attack and prescribe a specific duration of treatment. A severe asthma flare usually abates with treatment over 1-2 weeks; milder attacks resolve more quickly. Sometimes your provider will allow you to
adjust the duration of treatment on your own according to your response to
it. Once you are better, we anticipate
that you will continue to feel well and maintain good lung function if you continue taking your inhaled steroid
and, where possible, avoid the triggers that set off your asthma attack in the
first place.
