- Medication use for asthma
- Medication for asthma should be viewed in two broad functional categories:
- Which are the most effective intervention measures?
- Treating Asthma In Cats: Medications, Efficacy, & Side Effects
- Medications For Cat Asthma
- Other Methods For Managing Cat Asthma
- Prednisone – A Necessary Evil!
- Prednisone: a last resort for many
- The “cons” of prednisone
- Prednisone as Asthma Treatment
- Steroids for asthma
- Video: Steroids for asthma and their side effects
- When will your doctor prescribe steroids for your asthma?
- Steroid preventer inhalers for asthma
- Steroid tablets for asthma
- Getting the best from your steroid tablets
- Side effects of steroids
- Steroids FAQs
- Talk to our asthma nurses
- Questions to Ask When My Asthma Doesn’t Get Better
- Appropriate use of oral corticosteroids for severe asthma
- Oral corticosteroids in the management of acute exacerbation of asthma
Medication use for asthma
Miles Weinberger, MD
Professor of Pediatrics
Allergy, Immunology, and Pulmonary
Medication for asthma should be viewed in two broad functional categories:
- Intervention measures – those medications used to stop acute symptoms of asthma
- Maintenance measures – those medications used to prevent symptoms from occurring. However, maintenance medications do not prevent urgent medical care or hospitalizations from acute exacerbations of asthma and are therefor of no routine value for those patients whose asthma is limited to intermittent viral respiratory infection induced exacerbations, as is most common among preschool age children. Early use of intervention measures is essential for those acute exacerbations.
All patients with asthma require the availability of intervention measures. Only patients with chronic asthma or extended periods of persistent symptoms or airway obstruction require maintenance medication. However, no safe maintenance medication is reliably effective in preventing all acute exacerbations, especially those triggered by viral respiratory infections. Patients who have only intermittent asthma triggered by viral respiratory infections are not likely to benefit from maintenance medication at those times.
Which are the most effective intervention measures?
There are two categories of medication that, when used appropriately, provide highly effective intervention:
- Inhaled bronchodilators – these rapidly relax the spasm of bronchial smooth muscle that narrows the airway and creates obstruction to air flow.
- Anti-inflammatory corticosteroid medications taken by mouth or, if necessary, by injection – these decrease the mucosal edema and stop the mucous secretions that obstruct airways.
The most effective initial intervention measures are inhaled bronchodilators of the drug class known as beta-2 agonists. The most common of these is albuterol (known as salbutamol outside the United States). It can be delivered by various nebulizer devices and metered dose inhalers. Pirbuterol is closely related to albuterol and is therapeutically equivalent; it is available as a metered dose device that delivers the medication automatically upon inhalation (the brand name is Maxair Autohaler). There are several others available in this family but are less commonly used and have no advantage over albuterol and pirbuterol. As effective as these agents are for relief of acute symptoms, they provide no value as routinely scheduled medication.
Albuterol and other beta-2 agonists are also available in tablets and syrups for oral administration. However, they are much less effective by that route and have more side effects. Another inhaled bronchodilator unrelated to the beta-2 agonists is ipratropium (Atrovent). It is available as a nebulizer solution or metered dose inhaler. It has no routine role in the outpatient management of asthma but may be of value by aerosal in the emergency care setting when there is severe airway obstruction that responds inadequately to albuterol aerosol.
WARNING: The greatest danger from overuse of inhaled bronchodilators for intervention results from their prompt but often transient effectiveness. This can result in delayed recognition and progression of the inflammatory component of airway obstruction from asthma. The inhaled bronchodilators relieve only the airway narrowing from spasm of the bronchial smooth muscle. A short course of oral corticosteroids may be needed for patients who have progressive or prolonged periods of asthmatic symptoms as a result of airway inflammation. However, corticosteroids are slow to work, so it is important to recognize as early as possible when this inhaler is incompletely effective, suggesting that inflammation in addition to bronchospasm is present and that oral corticosteroids may be needed to prevent emergency care or hospitalization. While repeating the inhaler is appropriate if an initial use is incompletely effective, the need for a third use in a 4 hour period for recurrent symptoms or repeated use with decreasing periods of effectiveness requires a prompt call to your doctor for further advice.
When response to inhaled beta-2 agonist bronchodilators is incomplete, airway inflammation is generally a major contributor to the airway obstruction, and an anti-inflammatory corticosteroid medication is needed. The oral route is most effective for reversing the acute inflammatory process causing bronchodilator sub-responsiveness. The most common medications in this class used are prednisone, prednisolone, methylprednisolone, and dexamethasone. High doses for short periods of time (5-10 days) are safe and highly effective at reversing airway obstruction. If used early enough at adequate doses, this strategy prevents progression of asthmatic symptoms and avoids the need for urgent medical care or hospitalization. While high doses are generally well tolerated for this period of time, some people (about 10%) experience irritability and other minor side effects after the first day or two. Decreasing the dose at that time to once daily in the morning generally eliminates those side effects. Methylprednisolone appears to be less likely to cause such side effects. Prednisolone is available as liquid formulations. Orapred and a generic preparation from Morton Grove Pharmaceuticals at 3 mg/ml are the best tasting and most convenient of these liquid medications, which are always more expensive than their comparable solid dosage forms and certainly messier. Children can often be taught to swallow solid dosage forms without chewing (you don’t want to chew a prednisone or methylprednisolone tablet- they are very bitter). After all, they have all swallowed chewing gum or food particles larger than a tablet by that time. One successful technique is to use a non-threatening product like M&Ms or jelly beans and tell them that for each one they swallow whole, they get to chew the next two. Most catch on quite quickly. To assure a young child doesn’t get the taste of prednisone while swallowing the tablet (which will be a potential turnoff to future attempts), clear gelatin capsules can be obtained from a pharmacist and the tablet placed in that (breaking the tablet in half if necessary so it will fit). The traditional practice of many physicians of using tapering doses is irrational and inconsistent with controlled clinical trials in the medical literature. The best practice is to continue a high dose till symptoms are gone and then discontinue. If improvement has not unequivocally occurred by 5 days, or if there is not complete absence of symptoms by 7-10 days, further medical evaluation is needed.
While anti-inflammatory corticosteroid medications are available for inhaled and oral administration, the inhaled route is not optimally effective for treating acute symptoms. The oral or injectable route is therefore preferred for intervention when acute exacerbations of asthmatic symptoms occur. The inhaled route is best reserved for maintenance medication of chronic asthma with persistent symptoms. Injections of corticosteroids are no more effective than oral administration unless oral medication cannot be given or is not retained.
What are the choices for maintenance medication to prevent symptoms in patients identified as having a chronic or extended seasonal pattern of symptoms? Maintenance medication is indicated as a preventative measure for patients who have continuous or frequently recurring symptoms of asthma. These patients have asthmatic symptoms that promptly return even after being completely cleared with vigorous intervention measures. Since maintenance medication may be needed on a long-term basis, safety and convenience are prime considerations. In general, there are enough alternatives to avoid side effects from the medication, and any suspected side effects should be discussed with your physician. Each alternative has its own advantages and disadvantages. Maintenance medication needs to be systematically determined for each patient. No more should be used than is necessary to control the asthma. A single maintenance medication is often sufficient. Two medications should be used only if the two provide an advantage over one. More than two maintenance medications for asthma are occasionally justified for patients with severe asthma. Intervention measures must still be available for breakthrough symptoms. No maintenance medications reliably prevent all acute exacerbations, especially those triggered by viral respiratory infections.
For patients requiring long-term maintenance medications, careful consideration should be given to treatment measures that do not involve medication. Some patients have their asthmatic symptoms reduced with environmental measures. While some environmental exposures such as cigarette smoke and wood burning stoves are common irritants that can worsen asthma in many patients, others involve allergic reactions to substances that are otherwise harmless to nonallergic people. Identification of allergy as a cause of asthma requires evaluation by a physician knowledgeable about environmental allergens who will review the medical history of symptoms and perform tests to identify allergic antibody to environmental allergens. In some cases, the use of allergy shots may be considered as an effort to decrease sensitivity to inhalant allergens judged important in triggering asthma.
Once maintenance measures that control the asthma are determined, repeated re-evaluation at regular intervals helps assure continued safety and effectiveness of treatment in addition to assessing the continued adequacy and/or need for medication. Inhaled corticosteroids Inhaled corticosteroids that have a high degree of topical potency at low delivered doses have been available in the U.S. since 1977 with experience elsewhere for several years prior to that. They are the most effective single medications for asthma. These include beclomethasone dipropionate fluticasone (Flovent 44, 110 & 220), and budesonide (Pulmicort Turbuhaler and Respules). The inhaled corticosteroids have aquired a sufficient safety record that their use as an initial maintenance medication for chrinic asthma is justified. However, there are some potential side effects that appear to be dose related. Small decreases in growth have been shown, predominantly at higher doses (but uncontrolled asthma also has the potential to suppress growth). A very small increased risk of cataracts has been seen in adults; that risk appears to be related to the dose and duration of administration. Potential effects on bone metabolism have been suggested from sensitive biochemical studies, but development of osteoporosis seen with long-term daily oral corticosteroids has not been seen. However, since the potential for side effects, even if very low risk, justifies determining the lowest dose that provides good control of asthma, other medications can be added. These include salmeterol (Serevent) and slow-release theophylline, which when added to inhaled corticosteroids provide greater benefit than increasing the dose of inhaled corticosteroids.A combination product containing an inhaled corticosteroid (fluticasone) and salmeterol is marketed with three alternative concentrations of fluticasone, each with the standard dose of salmeterol (Advair 100, 250, and 500). Montelukast (Singulair) also provides some degree of added benefit when added to an inhaled corticosteroid. Oral corticosteroids Alternate-morning oral corticosteroids have been used for over 30 years as maintenance medications for asthma and other corticosteroid responsive diseases. The purpose of the alternate-morning schedule was a strategy to use the effectiveness of oral corticosteroids to suppress the disease while avoiding the well-recognized and potentially serious side effects of long-term daily oral corticosteroids. While most patients do not experience recognizable side effects from alternate morning oral corticosteroids, they have generally been used for asthma in combination with theophylline to obtain maximal clinical effect at doses of 20 to 40 mg every other morning. They are easier to use and less expensive than inhaled corticosteroids, but some patients gain weight with their usage because of appetite stimulation. The inhaled corticosteroids are generally more effective than alternate morning oral steroids and rarely cause weight gain. However, they do require more frequent administration, cost more, sometimes cause hoarseness and thrush, a minor fungal infection in the mouth, and are more frequently not taken as regularly as prescribed. Theophylline Theophylline is administered as an oral slow release capsule or tablet which require only twice daily administration. This medication had been the most commonly used maintenance medication for asthma in the U.S. for many years prior to extensive use of the inhaled corticosteroids in recent years, and it still has a high degree of efficacy as an initial agent or when added to inhaled or alternate-morning oral corticosteroids. The combination of theophylline and low dose inhaled corticosteroid is more effective than a higher dose of inhaled corticosteroid alone. The generic capsule from Inwood Laboratories can be opened, and the contents can be sprinkled on a spoonful of food for young children. Many patients appear to take an oral medication like theophylline more regularly than an inhaled maintenance medication. Only a morning and evening dose are needed. However, dosage needs to be individually adjusted based on a blood test to assure effectiveness and safety. Long acting inhaled beta-2 agonist bronchodilators Long acting inhaled beta-2 agonist bronchodilators such as salmeterol (Serevent) and formoterol are chemically related to intervention bronchodilators such as albuterol and pirbuterol but can last 12 hours. They are not a substitute for albuterol or pirbuterol for acute symptoms but are intended as daily maintenance treatment rather than as intervention for acute symptoms. Not generally recommended as initial therapy, their primary role is as additive therapy to inhaled corticosteroids. Combination products, Advair and Symbicort, provide a convenient means of providing the two medications in a single inhaler. Adding a long acting inhaled beta-2 agonist bronchodilator or theophylline to low doses of inhaled corticosteroid is generally more effective than higher doses of inhaled corticosteriod alone. However, there are occasional patients for whom these medications can make asthma more difficult to control with decreased response to their intervention inhaler used for acute symptoms. Worsening asthma with use of salmeterol or formoterol should promptly be discussed with the prescribing physician. Leukotriene Leukotriene modifiers include a medication, zileutin (Zyflo) that decreases the production of a leukotriene, a substance that is one of the mediators of inflammation in asthma, and two medications that antagonize the activity of that leukotriene, zafirlukast (Accolate) and montelukast (Singulair). Zileutin requires 4 times daily administration and has been associated with liver abnormalities; it therefore has little general appeal. Zafirlukast is a twice daily medication that is generally quite free of side effects but does have some potential for certain drug interactions and has been associated with a rare but serious disorder called the Churg Strauss syndrome, but the medication has not been established as the cause. The most common theory about the appearance of Churg Strauss Syndrome in patients taking leukotriene antagonists is that this is simply being unmasked as patients are withdrawn from their previous dose of oral corticosteroids used for what was believed to be asthma but was in fact supressing the symptoms and signs of Churg Strauss syndrome. Montelukast (Singulair) is currently the most commonly used medication in this class. It is a modestly effective medication that may be adequate for some patients with relatively mild asthma. Cromolyn (Intal) Cromolyn and a related medication with similar effect, nedocromil (Tilade) are inhaled medications that are relatively weakly potent, require multiple daily administration, and have little or no additive effect with other medications. They act by preventing the release of some mediators of the asthmatic response. Their primary merit is an almost complete lack of any serious side effects, even with overdose. Unlike the inhaled bronchodilators, cromolyn and nedocromil have no immediate effect and do not relieve acute symptoms. Although potentially effective for many patients with mild chronic asthma, they appear to be no more effective than montelukast, a once daily oral medication, and less effective than theophylline or inhaled corticosteroids. Ketotifen Ketotifen is an oral medication with antihistaminic effects that also is reported to have some of the effects of cromolyn or nedocromil. While popular elsewhere, studies regarding its efficacy for asthma have been unimpressive, and it has not become available in the U.S. Omalizumab (Xolair) Omalizumab is a humanized monoclonal antibody against immunoglobulin E (IgE), the allergic antibody that can cause allergen-induced asthma from airborne substances such as pollen, molds, dust mite, and animal dander. Given as an injection every 2-4 weeks (depending on the dose determined by body weight and the total IgE level measured in a blood test), this very expensive medication has the potential to almost completely eliminate the allergic antibody and thereby prevent that allergic antibody from causing asthma. The degree of benefit from Xolair is likely to relate to the extent to which allergy contributes to the individual’s asthma. Since asthma is a multifactorial disease, the extent to which allergy contributes to asthma ranges from none in some to a major component of the disease in others.
Treating Asthma In Cats: Medications, Efficacy, & Side Effects
Cat asthma is a respiratory condition in cats that is caused by inflammation in the airways. When exposed to a trigger or stress, an asthmatic cat has an immune response that constricts the airways. Coupled with swelling from inflammation, this response often leads to an asthma attack, a potentially life-threatening situation in which the cat has difficulty breathing
There is no ‘cure’ for cat asthma—it is a lifelong condition. However, there are several ways in which cat asthma can be treated and managed, from veterinarian-prescribed medications to diet and environment modification.
Medications For Cat Asthma
There are two main types of medications that are prescribed if a cat has been diagnosed with asthma: corticosteroids and/or bronchodilators. These are the same medications used to treat asthma in humans, but require different doses and administration in felines.
Corticosteroids (or glucocorticoids) are anti-inflammatory medications used to treat and manage the underlying causes of asthma1. Because asthma is a lifelong condition, corticosteroids should be taken routinely, even in the absence of symptoms, to manage asthma and prevent attacks. Corticosteroids are available as either systemic forms (those that affect the entire body), or inhaled forms (which target the airways directly).
In an emergency, your vet may use higher dose injectable or oral steroids to get an asthma attack under control. However, in the home environment, lower dose corticosteroids are used for daily disease management and should not be used to treat respiratory flare-ups or asthma attacks—bronchodilators should be used instead.
1. Systemic Corticosteroids
Systemic steroids are available in either injectable or oral (pill) form. Common oral corticosteroids prescribed for cat asthma include prednisone, prednisolone, and methylprednisolone. Prednisolone has higher bioavailability in cats and is generally preferred over prednisone2. Methylprednisolone (Depo-Medrol) is also a common injectable form of corticosteroid used to treat cat asthma3. These injections may be administered by your vet every few days to every few weeks depending on the severity of your cat’s asthma.
Administering Systemic Corticosteroids
Injections may be administered by your vet every few days to every few weeks depending on the severity of your cat’s asthma. Pills can be given by owners but are notoriously difficult to administer to cats, and often require force-feeding or attempting to hide pills in food.
Side Effects Of Systemic Corticosteroids
These types of corticosteroids must first be metabolized by the cat’s body, meaning that other organs can be affected in addition to the lungs and airways. Because of this, systemic steroid use can lead to many potential side effects, such as:
- Increased thirst and loss of bladder control
- Lethargy and no energy to play
- Immune suppression and increased risk of urinary tract infections (UTIs), and bacterial and fungal infections
- Behavioral changes, including aggression
- Weight gain
- Vomiting, diarrhea
- Ulceration of the digestive tract
- Cushings disease4
An additional drawback of injectable corticosteroids is that they can lose their efficacy over time, meaning the drug will need to be administered more frequently5. This can end up being quite costly for the pet owner.
Because of the risk of side effects, systemic steroids should not be used for long-term disease control.
2. Inhaled Corticosteroids
Inhaled medications deliver the drug directly to the lungs for effective results while using a lower dose of medication. The risk of side effects from corticosteroids is significantly reduced when using inhaled medication as it does not need to be processed by the body before reaching the lungs.
Inhaled corticosteroids, such as fluticasone (sold as Flovent HFA or Flixotide), are effective in treating inflammation associated with cat asthma. These medications are often taken once or twice daily to help control inflammation in the lungs.
Administering Inhaled Medications
When using inhaled medications, an aerosol chamber with a special mask that has been designed specifically for cats (such as the AEROKAT chamber) is required to help the cat breathe in the entire dose of medicine. Using the chamber and mask is easy and well accepted by cats, which is often surprising to pet parents.
Inhaled medications are safe for long term management of asthma and are considered the standard treatment choice for human children with asthma. For chronic conditions, inhaled corticosteroids should be used regularly, even in the absence of symptoms to manage the condition and keep airway inflammation down. Using inhaled steroids over other methods (such as pills or injections) help your cat maintain their playfulness and overall quality of life, so they remain a happy and active member of your family.
Bronchodilators are medications used to expand the airways6. They are commonly referred to as rescue medications because they are usually administered in the event of an asthma attack. These medications are often used in emergency situations rather than ongoing disease management. They have rapid action on the airways but their effects are generally short-lived and do not target the underlying inflammation.
Bronchodilators for cat asthma are also available in systemic and inhaled forms.
1. Systemic Bronchodilators
Systemic bronchodilators are available in oral or injectable form. Oral bronchodilators are difficult to administer to a cat in distress, as they may not be able to swallow a pill and must first be metabolized by the body before they take effect7. In these instances, an alternative form of bronchodilator is needed.
Bronchodilators are not often prescribed as injections for use at home. In emergency situations, terbutaline is a fast-acting medication that can be administered by a veterinarian to dilate the airways during severe, life-threatening asthma attacks8.
Side Effects Of Systemic Bronchodilators
Unfortunately, this medication can bring some unwanted side effects. Because epinephrine is a hormone that stimulates the fight-or-flight response, it can cause:
- Feelings of fear or anxiety
- Increased heart rate
- High blood pressure9
2. Inhaled Bronchodilators
Salbutamol, also known as albuterol, is an inhaled bronchodilator. It is often referred to by the brand names ProAir or Ventolin. These medications are fast-acting and can help a cat suffering an asthma attack within 5-10 minutes of receiving the dose.
As with corticosteroids, the risk of side effects from bronchodilators is significantly reduced when using inhaled medication. When inhaled, it does not need to be processed by the body before reaching the lungs, leading to quick relief for your cat.
An aerosol chamber (such as the AEROKAT chamber) must be used with the inhaler to help the cat breathe in the entire dose of medicine. During an attack, your cat’s breathing will be faster and shallower so it is important to use a chamber that can hold the medication long enough for your cat to inhale the dose. Using the chamber and mask is easy, and much less stress on both you and your cat compared to pills or injections. Inhaled bronchodilators can be administered at home or on the go, wherever and whenever your cat is experiencing an asthma attack or flare-up.
Other Methods For Managing Cat Asthma
In addition to corticosteroid and bronchodilator medication, there are ways to help manage cat asthma at home. Many of these strategies focus on controlling asthma attack triggers rather than the condition itself. There is little evidence to show these methods are effective as standalone treatments. Medication should always be the first line of treatment for cat asthma.
These methods may have a positive impact on inflammation and may help to prevent the onset of asthma attacks when used in conjunction with medication.
In some instances, antihistamines may be prescribed if the cat has significant allergies causing asthma attacks. Limited evidence is available to support antihistamines as a standalone treatment for cat asthma10.
- Follow a low allergen diet
- Manage obesity
Feeding your cat a low-allergen diet may help to reduce incidences of asthma attacks. Ask your vet for recommendations before switching your cat’s food.
Overweight or obese cats may already have breathing difficulties that worsen asthma symptoms11. Modification to your cat’s diet based on recommendations by your vet may help keep your cat’s weight in check.
- Ensure the cat’s environment is well ventilated, smoke-free, and clean
- Change air filters on a regular basis
- Avoid using fragrances, aerosols, and harsh chemicals
- Use unscented, low dust cat litter
Although there are ways to modify your cat’s environment to reduce the risk of asthma attacks, it is still important to take your cat to the vet. Medication is an important and potentially life-saving treatment for cat asthma. Talk with your vet about inhaled medications and how the AEROKAT chamber can help your cat live a happy and normal life.
3 “Methyl Prednisolone” PetMD. https://www.petmd.com/pet-medication/methyl-prednisolone
8 “Feline Asthma” Mar Vista Animal Medical Centre. https://www.marvistavet.com/feline-asthma.pml
10 “Asthma in Cats” International Cat Care. https://icatcare.org/advice/cat-health/asthma-cats
Prednisone – A Necessary Evil!
Prednisone is one of those nasty medicines that I dread, but sometimes it’s necessary when you have asthma.
For my kids, a course of prednisone (oral steroids) could sometimes prevent a trip to the hospital. We seemed like we had a 50/50 chance of preventing a hospitalization, but it was always worth the try!
Prednisone works really well to take the swelling down in your lungs. For the every day swelling that is part of asthma, my kids and I all use a controller inhaler. But sometimes, we can get really sick with bronchitis or pneumonia, and the regular controller inhaler just can’t get us through the rough patch.
Prednisone: a last resort for many
For us, it’s a sort of last resort to use prednisone. We will get more medication with prednisone (even for 3-5 days), than if using a daily, controller inhaler to keep the swelling down in our lungs. Why?
A controller inhaler is just that – inhaled – so the medicine goes in the lungs. Prednisone is given as a pill or liquid version and since you swallow it, it goes through your ENTIRE body – lungs, liver, kidneys, etc. It’s called a “systemic steroid” because it goes through your whole system.
How much more medicine would you get with one burst of prednisone, vs your daily inhaler (sometimes called an inhaled corticosteroid, or ICS)? One doctor did a little math to figure it out. This is what he said:
“In order to explain why regular ICSs are a good choice, I’ve got to do a little math. Let’s say you were just using a rescue inhaler for asthma control and that during the last year you only required one course of oral steroids, prednisone. A usual prednisone “burst” is 40mg a day for 5 days for a total of 200mg or 200,000mcg. By way of comparison, each dose of Advair 100/50 contains 100mcg of fluticasone, the steroid. If you took Advair 100/50 twice a day, the usual dose, it would take you 1000 days of regular use to equal the amount of steroids in one burst of prednisone on a mcg-per-mcg basis.”
So, we would rather take our daily inhaler, be exposed to less medicine over time, and have less side effects. But, sometimes we have no choice but to have a burst of prednisone.
The “cons” of prednisone
It can literally be a life saver- but it can have a LOT a side effects. Some of the common side effects are:
- sleep problems
- mood changes
- increase in appetite
- nausea, etc
It can also impair the immune system – which is a problem if you have asthma. The last thing you want to get is a cold, because it can turn into bronchitis or pneumonia. In fact, we are having that problem now.
Middle Son is in college and had a nasty case of bronchitis which required prednisone and an antibiotic. He was almost better until the Hubster brought home a terrible chest cold as a souvenir from our trip to Hawaii. Since Middle Son had an impaired immune system, and the Hubster’s cold was a different strain, Middle Son started a new battle with bronchitis – but it was much worse this time. He ended up on a 2nd antibiotic and was really struggling to breathe. It was scary. (It doesn’t matter how old my kids get, I’m going to worry – especially if they can’t breathe!)
Then, a few days later, he picked up a stomach bug. Poor guy! I think he picked up the 2nd cold and the stomach bug because he had been on a course of prednisone – which suppressed his immune system.
Everything has been disinfected, and we wipe down all of the surfaces every day to try to keep the germs away. But Middle Son still has to go to work and college (campus size is 30,000 students – can you imagine all of those germs?!)
If you do very sick and your doctor recommends prednisone, “the necessary evil”, discuss the benefits and side effects with her.
For us, the biggest benefit is that my son is still breathing and not in the hospital again. I’ll take prednisone over that any day.
Extra steroid doses
Because the body’s own natural steroid production is switched off when you take steroid tablets for a long time, it may not be able to respond quickly enough if suddenly your body needs an extra boost of steroid. So you will need to take extra doses of the steroid tablet instead. This can happen during illnesses.
If you are taking long-term steroid treatment you may need extra steroid during illnesses such as bad ‘flu, operations, asthma attacks and dental work or during any important health problem. See your doctor straight away if you become ill.
Your doctor may be able to help you plan ahead for certain problems.
If you are vomiting or unable to swallow tablets, contact your doctor urgently. You must not be without steroid medicine, particularly if you are unwell.
STOPPING LONG-TERM STEROID TREATMENT
For the same reason, it can be quite dangerous to stop long-term treatment suddenly – the body can find itself seriously short of steroid.
Anyone taking regular steroid tablets should wear a Medic-Alert bracelet. Then, if an accident occurs, and extra steroid is needed, the doctors will know.
When long-term treatment is to be stopped, this must be done very gradually. The dose must be slowly reduced, often over several months. This allows the body time to start making its own cortisone again, Slow reduction will also stop unpleasant side effects, such as severe muscle aches, arthritis and depression.
Slow reduction of steroid treatment must be done by your doctor, and the asthma carefully watched so it doesn’t worsen.
Prednisone as Asthma Treatment
Most people with asthma take daily medications to keep symptoms under control, but this isn’t always enough to prevent an asthma attack. That’s when you may need a stronger drug, such as prednisone, a corticosteroid. However, helpful as it is, this asthma treatment is not without side effects.
Prednisone is an oral corticosteroid drug used to treat an asthma attack — it is not used as a preventive medication. This asthma treatment works by reducing inflammation in the airways that cause the bronchi to constrict and make breathing difficult.
Are you doing everything you can to manage your asthma? Find out with our interactive checkup.
Prednisone is effective in people with asthma who are having a lot more difficulty controlling their asthma symptoms, whose symptoms have become more varied and frequent, and who have decreased lung function, explains Jonathan Bernstein, MD, an immunologist and professor at the University of Cincinnati in Ohio.
The Pros of Using Prednisone for Asthma Treatment
Prednisone can be a huge help for people like Carmen Spence, 30, of Louisville, Ky., who can’t always get relief from frequent-use medications.
“I take prednisone for bad asthma attacks,” says Spence, who typically uses an albuterol inhaler for mild asthma symptoms. “When I get a bad attack, my albuterol doesn’t work as well and I still have symptoms even after using it.”
When she can’t get relief from her inhaler and her peak flow (the measurement of exhaled air) readings drop, she reaches for prednisone. “It is extremely effective in managing my attacks. I usually notice an improvement within a day of starting prednisone and am feeling much better within just a few days,” says Spence.
As a short-term treatment — often between 10 to 14 days — prednisone is very effective in managing asthma symptoms and causes few treatment side effects, but that changes when used over the long term.
The Cons of Using Prednisone for Asthma Treatment
Prednisone has too many side effects to use it every day to keep asthma symptoms under control. “It’s not something you want to use on an ongoing basis ,” says Bernstein. “In the short-term it is fairly well tolerated.”
Even in the short term, however, you may experience:
- Increased appetite
- Irritation of the stomach
- Gastrointestinal problems
“Taking prednisone does cause me to have nausea and vomiting sometimes,” says Spence, “ when taking a high dose or if I haven’t eaten enough when I take a dose.”
Long term, the treatment side effects of prednisone become more serious. Risks and side effects of long-term prednisone use include:
- Weight gain
- Loss of bone mass
- Increased blood sugar or diabetes
- Increased susceptibility to infections
“You’re going to use oral prednisone when it’s necessary, when you’re having an acute attack,” says Bernstein. But at the same time, your need for it should be carefully evaluated. “When you have people on that degree of medicine, you want to make sure they’re compliant, that they have access to medication and can afford it.”
It’s also important for your doctor to evaluate you for other asthma triggers such as stress, GERD (gastroesophageal reflux disease), and other underlying medical problems. These problems can all complicate asthma and make it more resistant to treatment, Bernstein says, which would increase the need for prednisone.
Learn more in the Everyday Health Asthma Center.
Steroids for asthma
- How do steroids help asthma?
- Video: Steroids for asthma and their side effects
- When will your doctor prescribe steroids for your asthma?
- Steroid preventer inhalers for asthma
- Steroid tablets for asthma
- Getting the best from your steroid tablets
- Side effects of steroids
- Steroids FAQs
- Talk to our asthma nurses
How do steroids help asthma?
The steroids used to treat asthma are known as corticosteroids. Corticosteroids are copies of hormones your body produces naturally.
Steroids help asthma by calming inflamed airways and stopping inflammation. This helps ease asthma symptoms such as breathlessness and coughing. It will also help prevent your lungs reacting to triggers.
“You’re more likely to avoid high doses of steroids if you take your preventer inhaler every day as prescribed,” says Dr Andy Whittamore, Asthma UK’s in-house GP.
Video: steroids for asthma and their side effects
Video: Steroids for asthma and their side effects
Asthma UK’s in-house GP Dr Andy Whittamore explains how steroids work to help control asthma and why you shouldn’t worry about side effects.
Transcript for steroids for asthma and their side effects
0:00 As a GP, I do get people coming to see me worried about taking steroids for their asthma.
0:06 I do reassure them that the low doses we prescribe in inhalers is usually enough to control their asthma
0:13 without causing any major problems.
0:15 So they’re very safe, and trust me that they’re the most effective thing we have. Steroids work by calming down the
0:22 inflammation in the lungs. It’s that inflammation that not only causes symptoms such as cough, wheeze and
0:28 breathlessness, but it’s also inflammation that really gets flared up by pollens, pollution, stress, exercise, things like
0:36 that. So, by treating that underlying inflammation with a low-dose steroid inhaler, what we can do is help prevent people having symptoms and massive
0:46 flare-ups that end up with them being in hospital. If you need steroid tablets, whether they’re on a short-term basis or a very occasionally long-term, it’s again to treat the inflammation in the lungs, it’s just is having to treat a lot more
1:00 inflammation to try and keep you safe, and keep you well. For people who are
1:05 taking an inhaled steroid, so the brown preventer medication, for example, I do reassure them the low doses generally don’t cause a problem, but if they do get
1:14 problems, for example with the sore mouth, then to rinse their mouth out after they use their inhaler, to help prevent this, but if it’s still causing a problem then to speak to their GP or nurse about
1:24 different medications. Finally, the key thing is that steroid treatment is essential in the management of asthma.
1:31 Taking a regular preventative containing steroid can keep your lungs well, can keep you healthy and keep you doing the things that you enjoy doing.
When will your doctor prescribe steroids for your asthma?
Your doctor will prescribe steroids for your asthma if you need extra help with symptoms. They’ll prescribe the lowest dose of steroid medicines you need to treat your asthma symptoms and keep you well.
For example, your GP will prescribe steroid medicine if:
- you’re taking your reliever inhaler three or more times a week. Most people with asthma are prescribed a steroid preventer inhaler to use every day. It stops inflammation building up in your airways and cuts your risk of symptoms. So, if you’ve only been given a reliever inhaler, and you’re using it three or more times a week, see your GP.
- you’ve had an asthma attack. You might be given a short course of steroid tablets (prednisolone) to take until your symptoms are fully under control. These can quickly get the swelling in your airways back down again if you have an asthma attack.
- you’re getting asthma symptoms even when you’re taking your preventer inhaler as prescribed. This is when a course of steroid tablets may be what you need to get your asthma back under control.
- you have severe asthma. Some people with severe asthma are prescribed a longer course of steroid tablets at higher doses.
Steroid preventer inhalers for asthma
Preventer inhalers contain a low dose of steroids to prevent inflammation in your airways over time. This means you’re less likely to react to your asthma triggers.
“If you’ve been prescribed a preventer inhaler and are using it correctly, you’re less likely to need to take steroid tablets,” says Dr Andy. “Also, there’s very clear evidence that if you don’t smoke, your preventer inhaler works better, so you’re less likely to need steroid tablets.”
Steroid tablets for asthma
Steroid tablets also come in a soluble or liquid form. They contain a higher dose of steroids than a preventer inhaler.
Your GP will work out how much you need to take, and for how long, depending on your symptoms and how long it takes you to recover.
- For adults, steroid tablets are usually prescribed for at least five days.
- For children, steroid tablets are usually prescribed for at least three days.
- If you need a longer course of steroid tablets, your GP or asthma nurse will make sure these are prescribed at the lowest possible dose. You may need to take them for weeks or a few months at a time, depending on the number of steroid tablets you’re prescribed, or how long it takes you to fully recover.
“Your course of steroids may be longer depending on how long it takes you or your child to fully recover,” says Dr Andy. “It’s important that you come off them gradually if you’ve taken them for three weeks or more.”
Getting the best from your steroid tablets
“It’s important that steroid tablets are taken as prescribed, and that you see the course out,” says Dr Andy.
“You also need to carry on with your preventer inhaler so you can benefit from a lower dose of steroid tablets and give yourself more chance of a quick recovery.”
As well as this:
- Don’t be tempted to stop taking your steroid tablets before the course is finished. If you don’t finish the course your airways may still be inflamed. This means your asthma symptoms could come back again, putting you at risk of what could be a life-threatening asthma attack. Your GP can support you in coming off steroids gradually to cut your risk of symptoms
- Make sure you’re fully recovered.This means few, or no, symptoms (cough, wheeze, tightness in your chest, difficulty breathing) and not needing to use your reliever inhaler.“If you use a peak flow meter and your reading is back to above 75% of your personal best, that’s a good indication you’ve recovered too,” says Dr Andy.
- If you haven’t fully recovered, see your GP as soon as possible as you may need another course of steroid tablets to get the inflammation in your airways right down. It should be started as soon as you finish the first course – or as soon as possible. This is to make sure the inflammation in your lungs, which the steroid tablets are helping to control, doesn’t build back up again.
- Make sure your GP knows about other conditions you have like high blood pressure, stomach ulcer or diabetes. And any other other medicines you’re taking, like aspirin, ibuprofen or anti-coagulants, which could react with the oral steroids.
Side effects of steroids
Like all prescription drugs, there is a risk of side effects when you take steroids. But your GP will only ever prescribe them if the benefits outweigh the risks.
It’s also worth remembering that you’ll be kept on the lowest possible dose of steroids to manage your asthma, which will help minimise the chances of having side effects.
Side effects from your steroid preventer inhaler
Inhaled steroids (the ones found in your preventer inhaler) are usually in a very low dose and have few or no side effects. However, they can sometimes cause side effects like a sore throat or thrush.
“Using your inhaler in the best way, with a spacer, and rinsing your mouth out, cuts your risk of side effects – the steroid medicine you’re inhaling goes straight down into the airways and very little is absorbed into the rest of the body,” says Dr Andy. “If you’re taking a higher dose your GP or asthma nurse will keep a closer eye on you to monitor side effects.”
Find out more about your preventer inhaler and possible side effects here.
Side effects from a short course of steroid tablets
Most people who take a short course of oral steroids won’t experience significant side effects. You’re more likely to notice side effects if you’re on a high dose.
Although the dose of steroid going into your body is higher if you’re taking them in tablet form, any side effects like stomach upset, increased appetite, and mood swings are usually temporary and will stop once the course of tablets has finished.
Taking steroid tablets can also mean you’re more at risk from colds and viruses.
“Catching chickenpox when you’re taking steroids can cause you to become really unwell,” says Dr Andy. “If you’ve been around someone with chickenpox, see your GP to check your immunity.”
If you’re worried about any side effects, tell your GP or asthma nurse as soon as possible. They can give advice on how to reduce them. For example, if your stomach is upset after taking steroids, your GP may suggest taking the tablet with meals or after food.
“If you do get side effects from taking steroid tablets, it’s important to remember that the benefits far outweigh the risks, and your GP or asthma nurse will aim to get you on the lowest doses that will completely control your symptoms,” says Dr Andy.
Side effects from taking steroid tablets longer-term
If you take steroid tablets for three months or more continuously, or you have three to four courses a year, you’re more likely to get side effects.
These can include risk of infection, increased appetite, higher blood pressure, mood swings and depression.
“I’ve been taking steroid tablets for severe asthma for 11 years. I used to hate taking them and a few years ago decided to stop all my medication. I was in hospital 36 hours later. Even though the high dose of steroids I take causes some side effects, without them I wouldn’t breathe as well or have such a good quality of life. You need to balance it up.” – Jenny, diagnosed with severe asthma
Find out more about taking steroid tablets in the long term and how to manage side effects.
Side effects for your child with asthma
If you’re worried about your child taking steroid inhalers, or side effects from steroid tablets, speak to your GP or asthma nurse. You can also get some advice and reassurance about Common concerns about your child’s medicines.
In this section we answer some of your common concerns about taking steroids.
Will steroids affect my bone health?
The use of steroids has been associated with a risk of reduced bone density in some people. At your annual asthma review, your GP or asthma nurse can talk to you about your individual risk and what you can do to reduce this risk.
Will steroids make my face fat?
Some people who take steroids, particularly oral or injected steroids in the long term, may find they put on weight and notice they develop a “moon-shaped” face. This side effect is usually temporary and will stop once the course has finished. Your GP or asthma nurse will monitor this.
Will steroids cause diabetes?
The use of steroids, especially if you’re taking high doses, has been linked to an increased risk of developing diabetes.
Your GP or asthma nurse will keep an eye on your blood-sugar levels if you’re taking high doses of steroids by arranging blood tests and by testing your urine for glucose.
I’m pregnant. Is it safe to use my preventer inhaler, or take steroid tablets if I need them?
The medicines used to treat asthma are generally safe in pregnancy and won’t harm your baby. This includes your preventer inhaler and steroid tablets. There are more risks to both you and your baby if you don’t take your medicines and your asthma gets worse.
Do I need to carry a steroid card?
Anyone taking steroid tablets or a high dose of inhaled steroids, for more than three weeks should be given a steroid treatment card. This is so that if you ever need any medical treatment and you’re not able to communicate (you’re having an asthma attack, for example), the people treating you know that you’re taking prednisolone and can plan your treatment accordingly.
Talk to our asthma nurses
If you have any concerns or are worried about taking steroids, you can call the Asthma UK Helpline on 0300 222 5800 to talk to one of our asthma nurses. You can also message them via WhatsApp on 07378 606 728 (Monday-Friday, 9am-5pm).
To email an asthma nurse, fill in the Helpline Contact Form and you’ll receive a reply within three working days.
Last updated August 2019
Next review due August 2022
Questions to Ask When My Asthma Doesn’t Get Better
Asthma is a medical condition. It can be difficult to manage. Your efforts to treat don’t always work. This is especially true when a “trigger” causes your asthma to flare up. This may send you back to the doctor or the emergency room. If this sounds like you, don’t be discouraged. Below are common questions to ask yourself about what works and what doesn’t. Talk to your doctor to help you get back on track.
Is it really asthma?
Other illnesses can act like asthma. If your treatments aren’t working, maybe you don’t have asthma. Your doctor may want to do other exams or tests to confirm.
Is it something in my environment?
Some people who have asthma are allergic to things in their environment. These things can trigger their asthma. This could be at home, work, or school. If you know what it is, try to remove or avoid those things. This can help your asthma medicine work better. Common triggers of an asthma attack are:
- dust mites
- pet dander
- tobacco smoke
- certain pollutants
- cold, dry air
- viral infection
Your doctor can do skin or blood tests to figure out your triggers. Avoid these triggers to relieve your asthma symptoms and help your lungs work better. It might even reduce the amount of medicine you have to take. Talk with your doctor about ways to remove triggers from your environment.
Is it something in my workplace?
Some adults who have asthma are sensitive to something in their workplace. You might suspect this if your asthma flares up when you’re at work. Another clue is if some of your coworkers also have asthma symptoms. Perhaps your asthma is bad at work, but fine on weekends or vacations. Your doctor can help determine trigger. When you find out what that is, try to remove or avoid it.
Am I using my inhaler correctly?
It is important to use an inhaler correctly. If you don’t, you are not getting enough medicine into your lungs. Use a device called a spacer with your inhaler. This will help direct the medicine deeper into your lungs. Your doctor can prescribe a spacer and show you how to use it.
Am I taking my medicine correctly?
In order for your medicine to work, you must follow your doctor’s instructions. Many people who have asthma don’t follow their doctor’s orders. Take your medicine as prescribed. It will help prevent trips to the hospital and even asthma death.
Do I need to change medicines?
Medicines are available to help treat asthma symptoms. Most people who have asthma need at least two types of medicine. A preventive (“controller”) medicine keeps your lungs from becoming inflamed. A quick-relief (“rescue”) medicine helps your symptoms if the first one doesn’t work. If the medicines you take now aren’t helping, others may work. Allergy shots (immunotherapy) might help if your asthma is related to allergies.
Appropriate use of oral corticosteroids for severe asthma
To date, even with the introduction of the new biological agents, there remains a prominent role for OCS in the management of severe asthma. In the setting of the anti-IgE agent omalizumab for severe allergic asthma, in one review omalizumab has not been shown to allow a dose reduction in OCS.27 In a separate study, in patients treated with omalizumab for over a year, they still required a baseline, although lower, dose of OCS, particularly if they were intolerant of withdrawal of their biological agent, which may suggest an ongoing need for anti-inflammatory therapy.28 For patients treated with omalizumab, however, a treatment duration ≥ 60 months is better associated with the ability to step down treatment (including lowering OCS dose) compared with a shorter duration.29
The withdrawal of OCS has been more successful in the setting of treatment with the anti-IL-5 agent, mepolizumab; while only 14% of patients with severe eosinophilic asthma were able to discontinue their OCS entirely, a substantial dose reduction was possible, with 54% of participants decreasing maintenance OCS to or below 5 mg per day.30 The, anti-IL-5 receptor antibody benralizumab (recently approved by the Therapeutic Goods Administration, though not currently listed by the Pharmaceutical Benefits Scheme in Australia) has shown even greater promise as a steroid-sparing agent in patients with severe eosinophilic asthma, with up to 56% of patients studied being able to completely discontinue OCS. The remaining patients continued to use OCS, although at lower doses than at the onset of the study.31
Therefore, the experience, at least so far, with the biological agents has been that continued use of OCS is likely to remain important in a large proportion of patients with severe asthma, and even in the setting of these novel biological therapies, there is still a role for long term treatment with OCS as adjunctive therapy. Further study is required to determine why this may be the case, but it may be due to the multiple pathways through which corticosteroids have an anti-inflammatory effect in asthma. Nevertheless, given the potential adverse effects with OCS, it is hoped that this role will be reduced in the presence of biological agents.
Despite the long history of OCS use in severe asthma, there are no studies that have determined the optimal duration or dose to control the disease.2 There are two studies currently underway that aim to clarify how OCS could be used long term, combined with monitoring of biomarkers of inflammation, such as exhaled nitric oxide, peripheral blood eosinophil counts and serum periostin to titrate OCS dose.32,33 A previous case series of patients with overlap of asthma and chronic obstructive pulmonary disease showed marked improvements in symptoms and exacerbation rates through titrating OCS to suppress markers of type 2 inflammation, at least in those individuals with poor disease control and severe refractory eosinophilic inflammation.34 Given that these existing markers have been variably described to predict the presence of type 2 inflammation and that their use has been linked with reduced exacerbation rates in populations of patients with asthma, it is postulated that this method may help to achieve the delicate balance between using the required dose of OCS to control asthma, while minimising side effects. Although titrating OCS to target normalisation of biomarker values has shown promise in a pilot study,32 the optimal way to use these markers will require more definitive evidence.
The population with severe asthma is the last major cohort of patients with asthma who continue to be treated with long term maintenance OCS, and no discussion of the role of OCS would be complete without acknowledging the significant long term side effects of treatment which have been recognised since their early initial use in the 1950s. The most common serious complications include: bone density loss and risk of fracture, weight gain and metabolic syndrome, adrenal suppression and relative immunosuppression. In addition, patients variably experience neuropsychiatric symptoms such as insomnia, mania and anxiety, peptic ulcer disease, hypertension, dyslipidaemia, cataracts, glaucoma, bruising, fat redistribution (giving rise to “moon faces” and “buffalo humps”), skin striae, change in appetite, and worsening congestive heart failure or fluid retention.35 These side effects are most commonly described with doses above 10 mg per day of systemic corticosteroid, but there is evidence of a dose-dependent relationship with increased side effects from 6 mg per day upward.36 To mitigate some of these long term effects, monitoring of bone mineral density, blood pressure, blood lipids and glucose levels and assessment for adrenal insufficiency are suggested. In particular, the use of bisphosphonates to prevent osteoporosis is recommended, and gastric ulcer prophylaxis should be considered for those patients at risk.37 While many of these side effects are dependent on cumulative dosage, it is hopeful that, in the future, the further development of targeted therapies will reduce or avoid altogether the need for long term prednisone, and thus the development of these side effects.
Oral corticosteroids in the management of acute exacerbation of asthma
The most well defined and frequent use of OCS in the management of severe asthma is during an asthma exacerbation. The current Global Initiative for Asthma guidelines suggest that an asthma exacerbation is a progressive increase in symptoms sufficient to require a change of treatment.23 In the setting of severe exacerbations, this change in treatment usually entails the addition of a short course of OCS, which has been shown to be useful to prevent the need for visits to the emergency department (ED) and hospital, and prevent relapse of exacerbation in the subsequent weeks.38 Treatment with OCS forms the backbone of management of all severe asthma exacerbations. For patients capable of asthma self-management, self-treatment with a short course of OCS (about 1 mg/kg per day up to a maximum of 50 mg) is clearly effective at reducing relapse, need for additional care and required dose of β-agonists.39 Similarly, in those patients treated in primary care or in hospital who can tolerate oral therapy, OCS in the same dose range are effective for the treatment of asthma exacerbations.23 As long as patients are able to tolerate oral therapy, there is no proven benefit of intravenous therapy.38 The standard duration of OCS therapy that is effective is 5–10 days.40 In the acute care setting, it is suggested that OCS should be initiated within the first hour of presentation to the ED for patients presenting with acute exacerbation of asthma.41 It is not clear whether OCS are as effective in individuals with non-eosinophilic asthma. In one study in patients with moderate to severe asthma, the frequency of eosinophilic exacerbations was reduced by OCS, whereas non-eosinophilic exacerbations, which were the most common type, were not reduced.42 Further exploration is needed; however, there is no alternative treatment currently available.
In summary, OCS continue to play an important role in the management of severe asthma. In spite of their well known and significant side effects, they remain a crucial element in the management of this disease. Even with the availability of the novel biological therapies targeting IgE and IL-5, a large proportion of patients will continue to require OCS to control their asthma. It is estimated that up to 30% of patients with severe asthma still require the use of long term OCS, and they remain the only effective treatment to improve exacerbation frequency. This situation is unlikely to change in the near future.43 It is anticipated that their role will diminish with the advent of newer biological agents and more targeted therapy; however, although their use is often maligned or regretted, they cannot be replaced — at least for now. Further work should explore ways to optimise the balance between their efficacy and their safety.