A review warns against the risks of over-prescribing oral corticosteroids on some patients with asthma.

Dr Karl Gruber (PhD) explains

The use of oral corticosteroids (OCS) in patients with asthma should be monitored more closely in order to avoid potentially serious side effects, experts have warned.

It is one of the key messages of a new position paper that reviews our current knowledge on the use of OCS in asthma and the prevalence of side effects associated with overuse.  

The position paper, published in September in the journal Respirology, was written by experts in the field and is backed by the Thoracic Society of Australia and New Zealand. 

The paper makes recommendations on what doctors can do to minimise the use of OCS in asthma patients, and reduce harm associated with adverse side effects, such as weight gain, insomnia, mood disturbances and skin changes.

The authors recommend doctors use evidence-based strategies to reduce the need for OCS, such as avoiding ‘salbutamol only’ treatment, ensuring patients have a good inhaler technique, treating comorbidities efficiently, and referring early for biologic drugs.

In addition, asthma education, smoking cessation, specialist and multidisciplinary review and optimised medications can also help to reduce OCS use and improve patient health.  

Weight of numbers

Dr John Blakey, a consultant in respiratory and sleep medicine at Sir Charles Gairdner Hospital and an author of the new paper, says that because asthma is so common there are thousands of people experiencing preventable harm each year.

“There is a pressing need for OCS stewardship, that is to say a Goldilocks approach of using OCS when they are necessary, but taking all reasonable steps to reduce the need for their use and to minimise the cumulative dose when they are employed: not too much, not too little, but the right amount,” he said. 

Worldwide, around 300 million people suffer from asthma, involving intermittent airflow obstruction and bronchial hyper-responsiveness. In practice, people with asthma commonly experience symptoms like wheezing, coughing, shortness of breath and chest tightness or pain. 

In Australia, about 11% of the general population, or about 2.7 million people, reported having asthma according to a 2017-18 survey from the Australian Bureau of Statistics. For many of those affected, OCS are the first line of treatment.

“Around one in six people with asthma will have an attack this year requiring rescue treatment with oral corticosteroids. That equates to hundreds of thousands of prescriptions for OCS annually,” Dr Blakey said.  

Steroid downside

While in most cases asthma-associated symptoms can be controlled with inhaled corticosteroid medications, a significant percentage of patients experience side effects.

“In recent years we have recognised that a relatively small cumulative dose of OCS (500-1000mg prednisolone) increases the chance of adverse outcomes such as diabetes, depression, heart disease and blood clots,” Dr Blakey added.  

According to the data reviewed in this paper, the risk of depression and anxiety is three times higher in patients with asthma requiring maintenance OCS, compared to those patients who do not take oral steroids to control their asthma attacks. Likewise, asthma patients taking OCS seem to have an increased risk coronary heart disease, cerebrovascular disease and heart failure as well osteoporosis and fractures. 

The bottom line is that doctors who are treating patients with asthma should be mindful of potential side effects and consider alternative approaches.  

“The right treatment for the right patient from the right place. We hope this position paper will assist prescribers, but also make clear to people with asthma what the current standard of care is to give them the best chance of avoiding preventable harm from OCS,” Dr Blakey said.