Prednisolone for Acute Cough

Indications and Contraindications

The American College of Chest Physicians recommends against routine prescription of oral corticosteroids for acute bronchitis in immunocompetent adults, as high-quality evidence demonstrates no benefit in reducing symptom duration or severity 1, 2
The American College of Chest Physicians explicitly recommends against routine prescription of oral corticosteroids for acute bronchitis until treatments are proven safe and effective 1, 2
French guidelines state systemic corticosteroids are not justified for acute bronchitis in healthy adults, as the clinical course is spontaneously favorable after approximately 10 days 3
For severe paroxysms of postinfectious cough, prescribe prednisolone 30-40 mg daily for a short, finite period ONLY after ruling out other common causes (upper airway cough syndrome, asthma, gastroesophageal reflux disease) 4, 5, 6
For acute exacerbations of chronic bronchitis with sudden deterioration (increased sputum volume, purulence, dyspnea), prescribe a short course of systemic corticosteroids (10-15 days) 7, 3

The American College of Chest Physicians recommends a step-wise approach for postinfectious cough, starting with a trial of inhaled ipratropium, followed by inhaled corticosteroids, and finally oral prednisolone for severe paroxysms 4, 6
Recommended dose for acute exacerbations of chronic bronchitis: Prednisone 40 mg daily for 5-7 days or equivalent 3

Acute bronchitis vs. acute exacerbation of chronic bronchitis: Known chronic bronchitis (cough/sputum ≥3 months/year for ≥2 years) with sudden worsening = YES to steroids 7, 3
Duration-Based Algorithm: <3 weeks (acute): No prednisolone unless asthma/COPD exacerbation confirmed 1, 2
Duration-Based Algorithm: 3-8 weeks (subacute/postinfectious): Consider prednisolone only for severe paroxysms after other treatments fail 4, 6
Duration-Based Algorithm: >8 weeks (chronic): Investigate other diagnoses; not postinfectious cough 4, 6

Do not prescribe prednisolone based on wheezing or purulent sputum alone in acute bronchitis—these are not indications for steroid therapy 3
Do not use steroids hoping to shorten illness duration in acute bronchitis—evidence shows no benefit 3
Mistaking acute bronchitis for asthma exacerbation or pneumonia (which may benefit from steroids) is a common error requiring careful clinical assessment 3
If acute bronchitis worsens, reassess for bacterial superinfection or alternative diagnoses (COPD exacerbation, asthma, bronchiectasis) that may require different management including possible corticosteroids 1, 2