Oral Steroids for Asthma

Systemic drugs to treat acute attacks and severe persistent cases

In This Article

Oral corticosteroids are a type of drug taken by mouth that have their place in the treatment of asthma. They are most often used when a person has a severe asthma attack to rapidly reduce airway inflammation and relieve asthma symptoms. Oral steroids can also be used for the long-term control of severe asthma when other drugs fail to provide relief.

Though effective in controlling severe asthma symptoms, oral steroids need to used sparingly to avoid potentially serious side effects.

Uses

Corticosteroids, also referred to as oral steroids, are synthetic drugs that mimic the hormone cortisol naturally produced by the adrenal glands. They work by tempering a hyperresponsive immune system, reducing inflammation either locally (in a specific part of the body) or systemically (throughout the entire body).

Inhaled steroids do so locally as they are inhaled into the airways. Oral steroids, on the other hand, do so systemically as they are transported via the bloodstream.

Because oral steroids are prescribed at higher doses, they are used for specific purposes where the benefits of treatment outweigh the risks. They are most commonly used to treat asthma attacks (a.k.a. acute exacerbations) but can also be used to control asthma in people with advanced disease.

The four oral corticosteroids most commonly used for the treatment of acute or severe asthma are:

  • Prednisone
  • Prednisolone
  • Methylprednisolone
  • Dexamethasone

Oral steroids can be used in infants, toddlers, adolescents, teens, and adults with severe persistent asthma, albeit at different doses.

Acute Exacerbations

Oral steroids are mainly used in an emergency situation when a rescue inhaler is unable to resolve an acute exacerbation. The drugs are prescribed over a short period of time to speed the resolution of symptoms, prevent hospitalization, and reduce the risk of relapse.

According to a 2014 review in the Annals of Thoracic Medicine, around 23% of emergency department admissions in the United States are the result of a severe asthma attack.

Severe Persistent Asthma

Oral steroids can also be used to control symptoms in people with severe persistent asthma. This is the most advanced stage of the disease where a person's quality of life is severely impaired due to the frequency and severity of attacks.

When used for this purpose, oral steroids are prescribed under very specific conditions to reap the benefits of treatment while reducing the harms. The drug is taken daily at a lower than is used for emergencies.

Before Taking

There are steps a doctor will take before prescribing oral corticosteroids in an emergency setting or for the daily management of severe persistent asthma.

In Emergency Settings

The symptoms of acute exacerbations are relatively self-evident. They are defined as episodes of progressive increases in shortness of breath, cough, wheezing, and chest tightness accompanied by progressive decreases in expiratory airflow (the amount of air you can exhale).

In an emergency situation, the medical staff will quickly assess the severity of the attack to ensure the appropriate treatment. This will involve a review of your symptoms, prescription drug use, and medical history along with an evaluation of your blood oxygen levels using a pulse oximeter.

A handheld breathing device called a spirometer will also be used to evaluate your baseline lung function and to monitor your response to treatment.

The results can help the doctor classify your symptoms as being either mild, moderate, severe, or life-threatening. For all but mild exacerbations, intravenous and/or oral corticosteroids will be prescribed.

The current body of evidence suggests that oral steroids work just as effectively as intravenous steroids in people with moderate to severe exacerbations.

Other treatments may be needed to bring the attack under control, including oxygen therapy, inhaled bronchodilators, and anticholinergic drugs like Atrovent (ipratropium bromide) that help ease bronchoconstriction and bronchospasms.

Upon release from the hospital, you may be prescribed a short course of oral corticosteroids to take for several days to prevent a relapse of symptoms.

Classifying Your Disease

Severe persistent asthma is a classification of disease with clearly defined diagnostic criteria. If you do not meet it, an oral corticosteroid will likely not be prescribed.

To evaluate you for severe persistent asthma, your doctor will perform a series of pulmonary function tests (PFTs). These include tests called forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) that measure the strength and capacity of your lung before and after exposure to a short-acting bronchodilator.

These values, used in tandem with a review of your symptoms and medical history, can help confirm whether it is appropriate to add oral steroids to your current treatment plan.

Precautions and Contraindications

The only absolute contraindication for the use of oral steroids is a known allergy to the drug or any of the other ingredients in a formulation.

There are other situations in which oral corticosteroids must be used with caution. This typically applies to the ongoing treatment of severe asthma rather than the treatment of acute exacerbations. In an emergency situation, the risks are usually mitigated by the short course of treatment.

Because oral corticosteroids actively suppress the immune system, they may need to be delayed in people with an active bacterial, fungal, viral, or parasitic infection, including tuberculosis, ocular herpes simplex, measles, and chickenpox. Any active infection should be treated and fully resolved before starting oral corticosteroids.

High-dose corticosteroids can compromise gastrointestinal tissues and, in rare cases, lead to intestinal perforation. Oral steroids should be avoided in people with an active peptic or duodenal ulcer.

Corticosteroid drugs suppress the adrenal glands and should not be used with caution in people with adrenal insufficiency (Addison's disease). In these individuals, corticosteroids can trigger an adrenal crisis in which cortisol levels drop so low as to become life-threatening.

Corticosteroids can also cause long-term harm to the vision and should be used with caution in people with glaucoma or cataracts. The same applies to people with osteoporosis in whom the drug can cause further depletion of bone density.

Oral corticosteroids are classified as Pregnancy Category D drugs, meaning that animal studies have shown a significant risk of fetal harm (especially during the first trimester). Even so, the benefits of treatment may outweigh the risks if precautions are taken to avoid pregnancy.

Advise your doctor if you are pregnant before using oral corticosteroids or if you become pregnant while taking oral corticosteroids. Never stop treatment without first speaking to your practitioner, especially if you're on long-term therapy.

Dosage

The recommended dosage of oral corticosteroids varies by whether they are being used for an acute exacerbation or the chronic treatment of severe asthma.

For Acute Exacerbations

The optimal dose of oral corticosteroids depends on the severity of the acute exacerbation and the drug being used. Only a doctor can make this determination.

For adults, the dose of oral prednisone, prednisolone, or methylprednisolone is usually calculated at around 1 milligram per kilogram of body weight (mg/kg) in adults. Clinical studies have shown that doses between 30 mg and 80 mg per day are effective to treat moderate to severe exacerbations in adults and that doses higher than 80 mg do not confer to better results.

By contrast, dexamethasone is calculated at between 0.3 mg/kg and 0.6 mg/kg per day with a maximum dose of only 15 mg per day.

For non-hospitalized children, oral prednisone is generally preferred and dosed at between 1 and 2 mg/kg per day. For hospitalized children, intravenous methylprednisolone may be more effective at the same calculated dose.

Once the acute attack has been resolved, oral steroids may be prescribed for an additional five to 10 days to reduce the risk of relapse. For mild to moderate exacerbations, an initial emergency dose may be all that is needed.

For Severe Persistent Asthma

When used as a controller medicine, the daily dose of oral steroids is prescribed based on the following recommended ranges in adults:

  • Prednisone: 5 mg to 60 mg per day
  • Prednisolone: 5 mg to 60 mg per day
  • Methylprednisolone: 4 mg to 50 mg per day
  • Dexamethasone: 0.75 mg to 10 mg per day

The recommended dose in children is calculated at roughly 1 mg/kg per day for prednisone, prednisolone, and methylprednisolone. Dexamethasone is calculated at 0.3 mg/kg per day.

It is always best for those with severe persistent asthma to start with the lowest possible dose of oral corticosteroids and to only increase the dose if symptoms are not effectively controlled. An overdose of these medications can lead to vomiting, weakness, seizures, psychosis, and severe heart rhythm disruptions.

Once treatment is started, it can take up to two weeks before the full benefits are felt.

How to Take and Store

Prednisone, prednisolone, methylprednisolone, and dexamethasone are all available in tablet form. There are also oral syrups available for children or adults who are unable to swallow pills.

The drugs should be taken with food to reduce stomach irritation. To further reduce the risk of side effects, the doses can be split into a morning and evening dose on a strict 12-hourly schedule.

If you miss a dose, take it as soon as you remember. If it is near the time of your next dose, skip the dose and continue as normal. Never double up doses.

All of the oral formulations can be safely stored at room temperature, ideally between 68 degrees F and 77 degrees F. Keep the drug in its original light-resistant container and discard when expired. Keep the drug out of the reach of children and pets.

Side Effects

Because oral steroids affect the whole body, they pose a greater risk of side effects than their inhaled counterparts. Some of these side effects may develop soon after the start of treatment, while others will only develop months or years later with ongoing use.

Common

The side effects of prednisone, prednisolone, methylprednisolone, and dexamethasone are similar given that they have similar mechanisms of actions. Some of the more common side effects include:

  • Acne
  • Agitation
  • Dizziness
  • Headache
  • Weight gain
  • Muscle weakness
  • Nausea and vomiting
  • Numbness or tingling in the hands or feet
  • Pounding in the ears
  • Swelling of the lower legs or arms
  • Trouble concentrating
  • Trouble sleeping

Call your doctor if these side effects persist or worsen. Doses can sometimes be adjusted to help alleviate symptoms.

Severe

Prolonged exposure to oral corticosteroids can inhibit bone growth, impair hormone production, disrupt metabolism, and cause irreversible changes to your skin, vision, and brain.

Call your doctor if you or your child experience any of the following while taking oral corticosteroids:

The risk of side effects increases with the dosage and/or duration of therapy.

Warnings and Interactions

Because oral corticosteroids inhibit bone growth, children on prolonged therapy should be regularly monitored for impaired growth. Toddlers are most affected by this, and the termination of treatment doesn't always allow the child to catch up.

The early identification of growth impairment allows parents to make an informed choice about possible treatment options, including the use of the drug Zomacton (somatropin).

If oral corticosteroids are used for more than three weeks, they should not be stopped abruptly. Doing so may cause withdrawal symptoms and even trigger an acute exacerbation. People on long-term therapy may also experience an adrenal crisis if the adrenal glands are not given time to replace the lost corticosteroids with natural cortisol.

To avoid withdrawal, corticosteroid doses should be gradually tapered under the supervision of a doctor. Depending on the dose and duration of therapy, the tapering process may take weeks or months.

Drug Interactions

Oral corticosteroids can interact with many drugs. Chief among them are those that utilize the liver enzyme cytochrome P450 (CYP450) for metabolization. Corticosteroids also rely on CYP450 for metabolization and can end up competing for the available enzyme in the bloodstream.

The competition for CYP450 can affect the blood concentration of one or both drugs. If the concentration is reduced, the drug may be less effective. If the concentration is increased, side effects can occur or worsen.

Among the drugs or drug classes that can interact with oral corticosteroids are:

If an interaction occurs, your doctor may need to change treatment, adjust dosages, or separate doses by one or more hours.

People on high-dose corticosteroids may also develop an adverse immune reaction to live vaccines like those used to prevent smallpox, yellow fever, or chickenpox as well as the combined measle, mumps, rubella (MMR) vaccine.

People on high-dose steroids need to avoid live vaccines. If you have been on oral steroids for more than two weeks, treatment should be stopped for at least three months before receiving a live vaccine.

To avoid interactions, always advise your doctor of any drugs you are taking, whether they are prescription, over-the-counter, herbal, or recreational.

A Word From Verywell

If oral corticosteroids are prescribed for the long-term management of severe asthma, make every effort to keep to the dosing schedule. Do not stop treatment or store the drugs for an "emergency dose."

If you have problems with adhering to daily steroid treatment. let your doctor know. In some cases, the treatment plan can be adjusted to better accommodate your lifestyle and improve drug tolerability.

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