Optimal level of oral corticosteroids for asthma as close to zero as possible, expert says

Toronto - The optimal level of oral corticosteroids (OCS) for asthma should be as close to zero as possible, according to one of Canada’s top asthma doctors.That’s because the risks from chronic OCS use far outweigh the benefits even in patients with severe asthma. Yet there are new strategies available to keep asthma under at its best in these patients, according to Dr. Louis-Philippe Boulet, professor of medicine at Laval University. He spoke at the Canadian Thoracic Society (CTS) virtual annual meeting where he gave an overview of OCS use. He served on the CTS Respiratory Guidelines Committee as well as international asthma guideline groups.Worldwide, chronic OCS use is reported in 15% to 57% of patients with severe asthma, while their use in Canada ranges from 15% to 22%. Cumulative doses of prednisone tend to be more than 500 mg per patient per year, which is far too much, Dr. Boulet told The Medical Post.Severe and difficult-to-control asthma make up about 5% and 20%, respectively, of the asthma population. In the latter, poor control is often associated with asthma management problems that could be addressed.OCS remain an effective short-term treatment for acute severe asthma attacks in all severities of asthma and improve symptom control, but their used should be minimized with appropriate maintenance treatment, particularly with good adherence to inhaled corticosteroid which is generally combined with a long-acting beta-2 agonist. Even short courses increase the long-term risk of side-effects from this medication, he said.Chronic OCS use can lead to multiple induced comorbid conditions. One study of 808 severe asthmatics found 93% developed at least one comorbidity, including 14% who developed diabetes, 6% cataracts, 12% weight gain, and 28% pneumonia. Compared to non-OCS treated severe asthma, those using OCS regularly had a 1.4-fold increased risk of coronary heart disease, a 2.7-fold greater risk of cerebrovascular disease and 2.14-fold risk of heart failure.Multiple studies show such risks are dose-dependent, with high daily doses (10mg per day or more) of OCS leading to as much as a three-times greater risk for these conditions. Adverse events related to the drugs include bone loss leading to fracture in 21% to 30% of patients, and hypertension in over 30%.But even low-dose OCS use is associated with increased risk of both acute and chronic complications, which can lead to decreased quality of life, additional costs to the healthcare system and increased mortality, Dr. Boulet said. While chronic OCS use comes with significant risks, even a cumulative intake as low as a couple of weeks following short-term use may result in a increased risks, he said.So, what should doctors do?“It’s best to prevent OCS use in the first place,” Dr. Boulet said. First, confirm that a patient indeed has asthma. An estimated one third of patients diagnosed with asthma don’t actually have the disease. Many have heart or other respiratory conditions that have some similarities to asthma in terms of clinical presentation. Proving asthma with airway function tests is essential.Once the diagnosis is confirmed, the key is to ensure proper asthma control and prevent the need for OCS. The first step is help patients with strategies to avoid triggers, then ensure they can take their medications for best effect. Teach them to use their inhalers correctly and to use inhaled corticosteroids daily; look for overuse of rescue inhalers, and treat comorbidities such as rhinitis or GERD that may contribute to symptoms and poorer quality of health. Quickly consider non-biologic add-on therapy such as long-acting beta-agonists or, ideally, combination inhalers.Even mild asthmatics can have exacerbations. Recent Global Initiative for Asthma (GINA) reports suggest an inhaled corticosteroid and formoterol for both maintenance and rescue therapy may help prevent such exacerbations, particularly severe attacks requiring OCS.Do reassessments after three to six months or sooner if needed. If the asthma is controlled, consider stepping down the treatment. If it’s not well-controlled, refer to a specialist where possible, he said. This confirms the diagnosis and clarifies the severity of disease, identifies causal factors, (e.g. occupational asthma) and can include phenotyping when considering biologics in the more severe cases.If patients are already on chronic OCS, or are difficult-to-control, they should be referred to an expert centre to help get them get off. Patients can get into real trouble, and possibly die, from adrenal insufficiency if tapering is not managed well.“These patients should be under close supervision with a specialist when a progressive weaning of OCS is considered, once the patient has achieved adequate asthma control,” Dr. Boulet said.Long-term OCS use can cause the adrenal glands to stop producing sufficient levels of steroid hormones. Adrenal insuffiency symptoms are often non-specific and can be missed until the patient experiences an adrenal crisis.It’s now well understood there are several types of asthma. For those with severe disease, blood tests can determine the phenotype, and biologic agents which match the phenotype can be tried. Studies have shown biologic agents for asthma are effective in helping reduce OCS dependency in severe asthma. While high-dose inhaled corticosteroids and add-on medication are maintained during OCS tapering following adequate response to a biologic agents, asthma control and adrenal function are closely monitored.Five biologic agents are now approved for use in Canada: omalizumab, mepolizumab, reslizumab, benralizumab and dupilumab. They each target specific parts of the inflammatory cascade that can lead to asthma symptoms.Dr. Boulet recommended two guidelines for doctors: “Recognition and Management of Severe Asthma” position statement from the CTS, and “Difficult-to-Treat & Severe Asthma” from GINA.Dr. Krystelle Godbout, who moderated the CTS session, concurred with Dr. Boulet’s take on OSC. “Unfortunately, it is still impossible in 2021 to fully replace OCS in asthma. We must however acknowledge that their use, even in a few short intermittent courses, is associated with an increased morbidity. This should prompt physicians to stop prescribing OCS carelessly and use available tools to reduce their use. These include the use of action plans, ICS/formoterol as the reliever.”

Optimal level of oral corticosteroids for asthma as close to zero as possible, expert says

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