“Steroid use is prevalent among severe asthma patients, in part due to physician training that emphasizes the effectiveness of steroids rather than their potential dangers.”
Jane McDowell, MBBS BSc PhD is a respiratory doctor and currently serves as an academic clinical lecturer at Queen's University Belfast in Northern Ireland. She obtained her PhD from the Wellcome-Wolfson Institute for Experimental Medicine at Queen's under the guidance of Professor Liam Heaney. Her PhD focused on severe asthma - both the mechanisms that cause residual exacerbations in those treated with mepolizumab as well as the measurement of steroid-toxicity among those exposed to oral glucocorticoids.
“When I started my PhD, it was at a time when the only treatment option for severe asthma was oral glucocorticoids. In 2016, that changed with the licensing of several biologic treatments in the UK. This meant that instead of prescribing oral glucocorticoids, we could now give patients biologics, which should both reduce the number of asthma attacks or exacerbations and the incidence of steroid-toxicity.”
Dr McDowell and colleagues were the first researchers to employ the Steritas GTI in a clinical setting.
“At the time, the GTI had just been published but not applied to a patient cohort. Professor Heaney and I collaborated with Dr John Stone to convert the theory of the GTI into a clinically usable tool. We used our research in asthma patients to establish a cut point for what is a meaningful reduction in toxicity between time points.
Steroid use is prevalent among severe asthma patients, in part due to physician training that emphasizes the effectiveness of steroids rather than their potential dangers.
The real-life burden of steroids is significant and there is substantial evidence across various disease states showing just how commonly these adverse events occur and at relatively low doses.”
The Global Initiative for Asthma (GINA) estimates that asthma impacts 334 million people globally, with 13 million individuals (4%) experiencing severe, uncontrolled asthma despite efforts to optimize treatment.
“More than 50% of patients with moderate to severe asthma, have at least two courses of steroids every year - which is a huge number when you consider the number of patients involved.
Access to biologics varies greatly, and patients in many middle- and lower-income countries don't have access to biologics at all. However, even in higher income countries, access to biologics differs. Additionally, there is still an issue with educating clinicians on the consequences of steroid use and the necessity of assessing patients before prescribing steroids.
We are currently using the GTI to measure the burden of steroid-toxicity from oral glucocorticoids and quantify the steroid-sparing benefits of biologic therapies. We’re in the process of drafting our findings from a three-year longitudinal assessment of toxicity. It is disheartening to report that a considerable number of patients do not have much toxicity improvement even when steroid exposure is negligible.
The decrease in hospitalizations and exacerbations with biologics is very impressive, but there's no doubt that steroids do save lives. As clinicians, it's our job to use them mindfully, but also continue to look for better treatment options.”
Dr McDowell emphasizes the need for more patient education to enhance their knowledge of treatment side-effects, allowing for better-informed decisions and early recognition and management of these side-effects.
"I've had patients become extremely upset when they realize that their issues are a result of the use of steroids. Previously, we didn't have many alternatives, but as they have become available, we need to evaluate if and when steroids are required more carefully.
Moreover, we need to be cautious when tapering steroids and educate patients on how they might feel during the reduction.
We frequently receive feedback from patients indicating that they feel weak, and lethargic and experience joint pain as they taper off their steroids. While we endeavor to provide the best possible support throughout their journey, we know it can be challenging."
Jane McDowell, MBBS BSc PhD is currently an academic clinical lecturer at Queen's University Belfast. She earned her PhD from the Wellcome-Wolfson Institute for Experimental Medicine at Queen's under the supervision of Professor Liam Heaney. Her dissertation focused on the mechanisms underlying residual exacerbations in severe asthmatics treated with mepolizumab and the quantification of glucocorticoid toxicity in severe asthmatics treated with oral glucocorticoids. Her current research interests involve comprehending the underlying mechanisms that result in symptoms in severe asthmatics lacking elevated T2 biomarkers and investigating the changes in glucocorticoid toxicities over time in patients with severe asthma who have commenced biological therapies.