The Asthma and Allergy Foundation of America (AAFA) conducted a survey in 2018 to explore the impact of oral steroid use on patients with asthma,^[1] Oral corticosteroids (OCS) are an important tool in the management of asthma and are commonly used to reduce airway inflammation in patients experiencing acute asthma exacerbations. In the acute setting, they can reduce emergency room visits and hospitalizations for asthmatics. International guidelines recommend the use of oral steroids for severe asthmatics remaining clinically uncontrolled or at high risk of future loss of control, despite high dose of inhaled corticosteroids (ICS) plus another controller, such as long-term β2-agonists. The guidelines also repeatedly stress the need to reduce the use of oral corticosteroids with a focus on minimizing their use.^[2]

Despite these recommendations, it’s clear from the patient survey that oral steroid use – including longer-term use – is more widespread than recommended. The results of the survey make for a sobering read:

• Nearly 85% of patients had at least one course of oral steroids in the previous 12 months
• 64% had two or more bursts of oral glucocorticoids
• 78% of patients, under the care of an asthma specialist, had oral glucocorticoids prescribed by a non-asthma specialist
• While 70% of patients seeing an asthma specialist were told of the risks and side effects of oral steroids, more than half were unaware of the availability of innovative treatment alternatives to steroids for severe or hard-to-control asthma

One of the most striking findings of the survey was that patients were unaware that the need for oral corticosteroids was an indication that their asthma was not well controlled. These findings are consistent with results found in recent real-world studies covered in a previous paper on this site.  

The findings of this patient survey resulted in the formation of a collaborative effort to curb oral glucocorticoid overexposure in patients with asthma, through a range of initiatives.^[3] The aims of the collaboration were outlined in the Oral Corticosteroid Stewardship Statement, published in November 2018, as follows:

• Educating both patients and caregivers about the risk of oral steroid use, available treatment options and the importance of adhering to those therapies
• Enabling access to experienced asthma specialists
• Supporting the development of steroid-sparing strategies
• Encouraging government agencies and payers to modernize public health policies and support the funding of oral steroid-sparing therapies
• Support for healthcare providers in developing and adopting steroid-sparing strategies and practices through shared decision-making

The statement emphasized that, although oral corticosteroids were an important tool in treating asthma, the need for oral steroids to control symptoms should be seen as a signal that a patient’s treatment plan needs updating, or that they need support in adherence to medication. The initiatives set out in the statement were aimed at addressing this situation and ensuring that novel, steroid-sparing therapies were accessible to all asthma patients.

The Oral Corticosteroid Stewardship Statement as an instrument for change

The Stewardship Statement may not have resulted in a dramatic, overnight reduction in the use of oral steroids in asthma. It has, however, provided the foundation for longer-term change and a renewed focus on the need to reduce the chronic use of oral steroids. This change is exemplified by a number of initiatives started since the statement was published:

• Studies investigating the development of strategies for reducing steroid use in patients on steroid-sparing therapies^[4]
• Initiatives such as “The Great Taper” and “Steroids and Me (Sam)” specifically focused on supporting reduced use of oral steroids
• Position statements outlining how the Stewardship Statement’s recommendations can be put into practice by national agencies^[5]

Over time, the Stewardship Statement promises to effect real change in the use of steroids for the treatment of asthma around the world.

References

1. Oral corticosteroid health risks. https://aafa.org/asthma/asthma-treatment/asthma-treatment-oral-corticosteroids-prednisone/ (Accessed September 21st, 2024)
   https://ginasthma.org/wp-content/uploads/2024/05/GINA-2024-Strategy-Report-24_05_22_WMS.pdf. (Accessed September 21st, 2024)
2. Asthma and Allergy Foundation of America. Oral Corticosteroid Stewardship Statement, 2018. Available from: https://www.aafa.org/media/2244/oral-corticosteroid-stewardship-statement-november-2018.pdf
3. Menzies-Gow A, Gurnell M, Heaney LG et. al. Oral corticosteroid elimination via a personalized reduction algorithm in adults with severe, eosinophilic asthma treated with benralizumab (PONENTE): a multicenter, open-label, single-arm study. Lancet Respiratory Medicine, 10:47-58. (2022). https://doi.org/10.1016/ S2213-2600(21)00352-0
4. Blakey J, Chung LP, McDonald VM et al. Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand. Respirology, 26 (12): 1112-1130. (2021) https://doi.org/10.1111/resp.14147