Unnecessary use of high-dose oral steroids prevalent in patients with severe asthma

About one-third of patients with severe asthma who are on high-dose inhaled corticosteroids (ICS) are also receiving excessive doses of oral corticosteroids (OCS), reveals a study presented at the ERS 2019 Meeting.  

Among these patients, more than three quarters were either nonadherent to their ICS or had incorrect inhalation technique — indicating that a majority of them could avoid taking OCS by improving their adherence to inhaled medications and their inhaler technique, according to Dr Katrien Egar from Amsterdam University Medical Centre in Amsterdam, the Netherlands.

“Every prescription for oral steroids should alert doctors to assess adherence to inhaled therapies and inhalation techniques in these patients,” she highlighted.

Among 929 patients with severe asthma receiving high-dose ICS as identified in a pharmacy database, 29.5 percent also received high doses of OCS (median, 750 mg/year of prednisone-equivalent doses). [ERS 2019, abstract OA5334]       

Of these, 78.1 percent of the patients were nonadherent or demonstrated poor inhalation technique. The remaining 21.9 percent patients who were adherent with good inhalation technique were candidates for biologic treatment, but only 46.1 percent of these were currently receiving biologics.

“If we extrapolate our results from the database to the general Dutch population, this would mean that there are about 6,000 patients with severe asthma who are candidates for biologic treatment – 1.5 percent of the whole asthma patient population … This shows that there is potential to substantially reduce oral steroid overuse,” said Egar.

“Now that there is an increasing number of biologic asthma drugs available that avoid the need for oral steroids, doctors should initiate biologic treatment in suitable patients to reduce exposure to harmful oral steroids,” she added.  

Nonetheless, she pointed out that both ICS adherence and inhalation technique should be addressed first in the 78.1 percent of patients with these issues before considering them for biologic treatment.

“OCS overuse is unnecessary in a large proportion of asthma patients,” said Egar.

The issue with steroid overuse

“OCS are an important medication for acute treatment of moderate to severe asthma flare-ups; they reduce inflammation in patients’ airways during acute exacerbations to make it easier to breathe again, thereby helping to reduce the risk of hospitalization,” ERS Chair Professor Guy Brusselle from Ghent University in Ghent, Belgium.

However, frequent or long-term use of OCS comes with many side effects, with greater risk at higher doses.

“Asthma patients using high doses of OCS are at risk of serious adverse effects such as diabetes, osteoporosis and adrenal insufficiency, in which the adrenal glands do not produce adequate amounts of steroid hormones,” Egar stated.  

“If they reduce exposure to harmful oral steroids and thus reduce the adverse effects, this could lead to a reduction in the cost of healthcare. Another important way to look at this, is that patients can exercise more and experience fewer exacerbations of their disease, and so have fewer days off work due to illness,” she said.