Rational oral corticosteroid use in adult severe asthma: A narrative review

Abstract

OCS play an important role in the management of asthma. However, steroid-related AE are common and represent a leading cause of morbidity. Limited published studies suggest OCS usage varies across countries and recent registry data indicate that at least 25-60% of patients with severe asthma in developed countries may at some stage be prescribed OCS. Recent evidence indicate that many patients do not receive optimal therapy for asthma and are often prescribed maintenance OCS or repeated steroid bursts to treat exacerbations. Given the recent progress in adult severe asthma and new treatment options, judicious appraisal of steroid use is merited. A number of strategies and add-on therapies are now available to treat severe asthma. These include increasing specialist referral for multidisciplinary assessments and implementing OCSsparing interventions, such as improving guideline adherence and add-on tiotropium and macrolides. Biologics have recently become available for severe asthma; these agents reduce asthma exacerbations and lower OCS exposure. Further research, collaboration and consensus are necessary to develop a structured stewardship approach including realistic OCS-weaning programmes for patients with severe asthma on regular OCS; education and public health campaigns to improve timely access to specialized severe asthma services for treatment optimization; and implementing targeted strategies to identify patients who warrant OCS use using objective biomarker-based strategies.

Cumulative dispensing of high oral corticosteroid doses for treating asthma in Australia

“…[18][19][20][21] A subset of patients with a severe asthma phenotype are eligible for targeted therapy with new monoclonal agents that can reduce attack frequency and therefore the need for short course OCS therapy. 22,23 Patterns of OCS prescribing in the community should be further examined to determine when it reflects inadequacies in management (education, home monitoring, early detection, action plan), when it reflects severe uncontrolled disease, and when it is unnecessary. This will guide efforts to improve the appropriateness of OCS prescribing.…”

Development and Clinical Application of a Prednisolone/Cortisol Assay to Determine Adherence to Maintenance Oral Prednisolone in Severe Asthma

“…However, a recent systematic review reported continuing use of maintenance OCS in 20% to 60% of patients with severe asthma. 27,28 Delay in access to biologic treatment, not meeting prescribing criteria, lack of response, or achieving only a partial response are some of the drivers of continuing use of maintenance OCS in severe asthma. In patients who experience good response to biologic treatment, tapering and weaning off OCS would require concomitant assessment of adrenal function, which can be performed by using this LC-MS/MS assay with no need to stop the prednisolone treatment on the day of the test.…”

Perception of oral corticosteroids in adult patients with asthma in France

“…However, OCS-related adverse events, such as those affecting the cardiovascular, gastrointestinal, and musculoskeletal systems, as well as infections, are common and such events can be fatal. These OCS-related sideeffects have been reported to be more frequent in patients with severe asthma who are under daily maintenance treatment than in those with severe asthma who have frequent rescue courses and in those with mild/moderate asthma (3,13,14). Indeed, crosssectional data from the Optimum Patient Care Research Database and the British Thoracic Difficult Asthma Registry reported a prevalence of OCS-related comorbidities of 34% for high blood pressure, 16% for osteoporosis, 10% for type 2 diabetes, 10% for cardiovascular disease, 9% for cataract, 4% for glaucoma (3,(15)(16)(17).…”