Appropriate use of oral corticosteroids for severe asthma | The Medical Journal of Australia - Introduction
Looking for:
- Corticosteroids - clinical applications: exacerbations of asthma in adults - Australian Prescriber |
Prednisone for Asthma: Usage, Efficacy, and More.
The role of oral prednisolone in an acute asthma exacerbation is. Prednisone for Asthma: Does It Work?
In one trial, patients were randomized into three groups of 1-day dexamethasone, 2-days dexamethasone, and prednisone Data of both dexamethasone groups were compared separately with prednisone in our meta-analysis. The dosage of dexamethasone in the included studies was 0. Majority studies had an institutional asthma management protocol wherein additional drugs were given to all patients of the trial.
Inhaled or nebulized salbutamol, albuterol, and ipratropium bromide were commonly administered in the included studies. The follow-up period ranged from 1 to 15 days. For the meta-analysis, two sub-groups were created based on the follow-up period of relapse rates 1—5 days and 10—15 days. There was no significant difference in the relapse rate between dexamethasone and prednisone at 1—5 days RR 1.
With an overall relapse rate of 8. Sub-group analysis was carried out for 1-day and 2-days dosage of dexamethasone vs. Figure 2. Forrest plot for dexamethasone vs. Figure 3. Hospital readmission after initial discharge was evaluated by four trials 7 , 13 , 18 , With a re-admission rate of 1. Data on the incidence of vomiting in ED were retrieved from four studies 7 , 13 , 18 , Patients receiving dexamethasone vomited less frequently as compared to prednisone RR 0. The frequency of vomiting at home was significantly higher with prednisone 5.
Figure 4. Figure 5. There was no change in direction of effect size on sensitivity analysis for the variables: relapse rate, hospital readmission, and vomiting at home. However, when the results of Qureshi et al. Figure 7. For the outcome variables, relapse rate and hospital readmission rate, all studies were underpowered.
The weighted mean effect size for relapse rate was 0. The power of our meta-analysis for detecting significant difference in relapse rate was For the variables, vomiting at ED and vomiting at home, the weighted mean effect sizes were 0. The authors' judgment of the risk of bias is presented in Figure 8. Randomization was adequately described in five studies 1 , 13 , 18 , 20 , An appropriate method of allocation concealment was utilized in four trials 1 , 13 , 18 , Only three studies 1 , 18 , 20 provided sufficient information on blinding of participants and personnel while only two trials 1 , 18 reported blinding of outcome assessment.
Attrition bias was found to be high in two studies 19 , Figure 8. Risk of Bias assessment. Green, low risk of bias; Yellow, unclear risk of bias; Red, high risk of bias. Management of acute asthma exacerbations in children not only depends on the therapy provided in the ED but also on strict adherence to medications prescribed on discharge. On the other hand, Butler et al.
Non-compliance to medications on discharge has been attributed to several factors like inadequate funds or lack of insurance, insufficient knowledge on the necessity of treatment, fear of side-effects and prolonged course of treatment 3 , 8 , Dexamethasone, a long-acting corticosteroid, has been studied as an alternative to prednisone to allow a shorter course of treatment in asthmatic patients 4.
While inhaled and single-dose IM dexamethasone may be used as a substitute to prednisone, oral formulation is preferable in managing children 9 , Studies conducted on adult asthmatic patients have found no difference in relapse rates with 2-days oral dexamethasone and 5-days prednisone 24 , Rehrer et al. In our study, while comparing the use of oral dexamethasone and prednisone in pediatric asthma exacerbations, we found no difference in relapse rates between a short-course of dexamethasone as compared to the standard 3—5 days therapy of prednisone.
The hospital readmission rates after initial discharge were slightly higher with dexamethasone as compared to prednisone 1. The results of our study are similar to the previous meta-analyses on this subject. Keeney et al. However, results from both IM and oral dexamethasone trials were pooled in their analysis. Normansell et al. In comparison, while our updated review was able to include three more RCTs, we also conducted a power analysis to identify if the included studies and our meta-analysis was adequately powered to detect significant difference in outcome variables.
It is important to note that despite pooling of data from seven RCTs, our meta-analysis was underpowered to detect significant difference in relapse rates and hospital readmission rates between dexamethasone and prednisone.
In a sub-group analysis, we also compared 1-day and a 2-days course of dexamethasone with 3—5 day therapy of prednisone. However, with just one trial reporting a three-way comparison of 1-day and 2-days dexamethasone with prednisone 19 , combined with limited power of our meta-analysis, conclusion cannot be drawn till further studies are carried out to explore the differences between 1 and 2-days dexamethasone protocol.
It is also important to note that relapse rates and hospital readmission rates may be influenced by factors like clinical decisions, hospital criteria for admission and accessibility to healthcare facilities The criteria for relapse rate are also broad varying from the visit of the child to a family doctor for continued wheezing and cough to a severe relapse requiring in-patient management Therefore, objective measures of reduction in asthma severity and assessment of persistent symptoms may better evaluate the differences in the two steroid treatment protocols.
Elkharwili et al. Paniagua et al. PRAM scores were measured at day 4 of treatment by Cronin et al. Altamimi et al.
With a mean of 5. While individually all included studies reported dexamethasone to be as efficacious as prednisone, methodological heterogeneity of outcome measures precluded a meta-analysis of such variables in our study.
Despite intra-venous dexamethasone and prednisone demonstrating similar efficacy for preventing nausea and vomiting after chemotherapy 28 , the unpleasant taste of oral prednisone frequently results in vomiting especially in children While the difference of taste between dexamethasone and prednisone has reportedly not been a hindrance in treatment adherence 21 , vomiting may affect treatment compliance in pediatric patients Hames et al. In our meta-analysis, vomiting at ED and home was found to be significantly higher with prednisone as compared to dexamethasone.
Similar results have been reported in the meta-analysis of Keeney et al. The strengths and limitations of our study need to be elaborated. Firstly, in our review three more RCTs were added since the last published meta-analysis, thereby providing an updated evidence. Secondly, a sensitivity analysis was carried out to assess influence of individual studies on the overall results. Lastly, power analysis was also carried out to provide a guide to readers on the validity of the calculated results.
The results of our review, however, should be interpreted with caution due to the following limitations.
Additionally, lack of adequate randomization and allocation concealment, as well as attrition bias in some studies, could have influenced the overall results. Secondly, there was considerable methodological heterogeneity amongst the seven trials especially concerning drug dose, duration of therapy, utilization of additional drugs, follow-up protocol, etc.
Thirdly, inclusion criteria varied amongst studies, with the trial of Paniagua et al. Asthma is usually not diagnosed at such a young age due to the prevalence of bronchiolitis in this age-group Lastly, our meta-analysis was not adequately powered to detect differences in relapse rates and hospital readmission rates, as out of the seven included trials, three studies 1 , 19 , 20 were of small sample size recruiting only 23—51 patients per group.
In our power analysis, all included studies were found to be underpowered for detection of significant difference in the primary outcome variable.
To conclude, despite our results indicating similar relapse rates and hospital re-admission rates with dexamethasone and prednisone when used for acute asthmatic exacerbations in children, strong conclusions cannot be drawn due to paucity of large scale RCTs and limited quality of evidence.
It is also not known if both drugs are equally efficacious in reducing asthma severity. Our results however indicate that, vomiting is significantly less with dexamethasone as compared to prednisone. Further large-scale homogenous RCTs comparing the two drugs are warranted to establish guidelines for the use of oral steroid therapy in acute asthma exacerbations in children.
JW and QC conceived and designed the study. JW was involved in the writing of the manuscript. All authors have read and approved the final manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Single-dose oral dexamethasone compared with three day course of oral prednisolone in children with moderate exacerbation of asthma-a pilot double-blinded randomised controlled trial.
J Clin Diag Res. Scarfone RJ, Friedlaender E. Corticosteroids in acute asthma: past, present, and future. Pediatr Emerg Care. Different oral corticosteroid regimens for acute asthma.
Cochrane Database Syst Rev. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Is dexamethasone as effective as prednisone or prednisolone in the management of pediatric asthma exacerbations? Ann Emerg Med. British Guideline on the Management of Asthma. PubMed Abstract Google Scholar. Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. J Pediatr. Butler K, Cooper WO. Adherence of pediatric asthma patients with oral corticosteroid prescriptions following pediatric emergency department visit or hospitalization.
This is done in order to identify the minimum maintenance dose of corticosteroid to maintain control of the asthma. When suppression of the hypothalamic -pituitary-adrenal axis has occurred from chronic corticosteroid usage, dose tapering should proceed very slowly over months with monitoring of plasma cortisol. Controlled studies have not yet defined the best way to reduce the dose of inhaled steroids after exacerbations. One approach is to reduce the dose at weekly intervals in order to identify the minimum maintenance dose of inhaled steroid.
Inadequate response Inadequate response is not infrequent during exacerbations of asthma. These can be addressed by education and preparing an asthma action plan. As there is no specific therapy for mucus plugging in asthma, there may be a slow response to therapy when this is present. The clinical relevance of individual variations of corticosteroid metabolism remains undefined.
Influences on treatment There are a number of additional factors to consider when choosing therapy for patients. Oral prednisolone is preferred if there is a history of severe asthma, life-threatening asthma, non-response to inhaled corticosteroids, or chronic use of high-dose inhaled corticosteroids or daily oral steroids.
In mild exacerbations, oral steroids are avoided if there is a history of adverse reactions, non-compliance, steroid phobia, or diabetes mellitus. In acute exacerbations of asthma, intravenous hydrocortisone is more effective than oral prednisolone. Reasonable care is taken to provide accurate information at the time of creation.
This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise disclaims all liability including for negligence for any loss, damage or injury resulting from reliance on or use of this information.
Read our full disclaimer. This website uses cookies. Read our privacy policy. Skip to main content. Log in Log in All fields are required.
Log in. Forgot password? Home Australian Prescriber Corticosteroids - clinical applications: exacerbations of asthma in adults A A. Gibson PG. Corticosteroids - clinical applications: exacerbations of asthma in adults. Aust Prescr ; Article Authors. Subscribe to Australian Prescriber. Pathogenesis An exacerbation of asthma involves bronchospasm airway inflammation with cellular infiltration and oedema mucus plugging.
Action plans instruct the patient when to increase treatment how to increase treatment for how long to take the increased treatment when to call the doctor. Which route of administration? Oral prednisolone is added if there is a recent history of a severe exacerbation a history of treatment failure with inhaled corticosteroid an unreliable inhalation technique no response after several days.
Self-test questions The following statements are either true or false. Corticosteroids have little effect on the mucus plugging which occurs in acute asthma Answers to self-test questions 1. False 2. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis.
Am J Emerg Med ; Engel T, Heinig JH. Glucocorticosteroid therapy in acute severe asthma - a critical review. Eur Respir J ; Corticosteroids in acute severe asthma: effectiveness of low doses [see comments]. Thorax ; Comment in: Thorax ; Webb JR. Dose response of patients to oral corticosteroid treatment during exacerbations of asthma.
Br Med J ; Acute dose response studies in bronchial asthma with a new corticosteroid, budesonide. Br J Clin Pharmacol ; Timing of prednisone and alterations of airways inflammation in nocturnal asthma. Am Rev Respir Dis ; A research method to induce and examine a mild exacerbation of asthma by withdrawal of inhaled corticosteroid.
Clin Exp Allergy ; Levy M, Stevenson IC. A comparison of the efficacy of inhaled fluticasone propionate 2 mg daily and a reducing course of oral prednisolone in the treatment of acute exacerbations of asthma. Br Med J. In press. Double-blind trial of steroid tapering in acute asthma [see comments]. Lancet ; Comment in: Lancet ; Med J Aust ; Peter G.
About Australian Prescriber Contact us. Date published: 01 April Reasonable care is taken to provide accurate information at the time of creation. How likely is it that you would recommend our site to a friend? Please help us to improve our services by answering the following question How likely is it that you would recommend our site to a friend? Please feel free to tell us why.
Which of the following best describes you? Medical Specialist. Other health profession. Which of the following best describes how frequently you visit this site? This is my first visit.
Background: This systematic review and meta-analysis was conducted to compare relapse rates and adverse effects with oral dexamethasone vs. Dosage of dexamethasone and prednisone varied across studies. Studies were grouped based on the follow-up period and duration of dexamethasone administration.
Results: There was no significant difference in the relapse rate between dexamethasone and prednisone at 1—5 days RR 1. Pooled analysis found no significant difference in relapse rates with 1-day RR 1. Hospital readmission rates after initial discharge were not significantly different between the two drugs RR 1. Frequency of vomiting at ED RR 0. Conclusion: While our results indicate that both dexamethasone and prednisone have similar relapse rates when used for acute asthmatic exacerbations, strong conclusions cannot be drawn due to paucity of large scale RCTs and limited quality of evidence.
Dexamethasone is however associated with lower incidence of vomiting as compared to prednisone. Further homogenous RCTs are needed to provide robust evidence on this topic.
Asthma is a common pediatric disease that results in significant limitation of activity and an estimated loss of The disease is characterized by chronic airway inflammation, airway edema, bronchoconstriction, and airway hyperresponsiveness which results in respiratory symptoms like wheezing, shortness of breath, chest tightness, and cough 2.
The intensity of the disease varies with time and episodes of exacerbation frequently require management in the pediatric Emergency Department ED 3. The primary line of treatment in acute exacerbations of asthma is directed at a quick reversal of bronchospasm and reduction of airway inflammation 4. For this purpose, oral steroids are extremely effective for alleviating symptoms in children 5.
Early use of oral steroid therapy is also recommended with prednisone being the drug of choice 6. Relapse after prednisone therapy has been attributed to several factors like the unpleasant bitter taste of the drug, side-effects like vomiting, and its multi-dose regimen of 3—5 days which may reduce patient compliance 8 — To improve patient compliance and reduce relapse rates, the role of dexamethasone has been evaluated in many trials 47. Initial studies evaluating a single dose of intramuscular IM dexamethasone have found it to be as effective as a 3—5 day regimen of prednisone 11 Subsequently, studies have also compared oral 1 or 2-day therapy of dexamethasone against a 3—5 days regimen of oral prednisone 4 Oral formulations are desirable in children as they are associated with less pain.
To date, two meta-analyses have compared oral dexamethasone and prednisone for acute exacerbations of asthma in children, with the last literature search performed in April 34. Due to the limited number of studies analyzed in these previous reviews, this study aimed to provide an updated Level 1 evidence on relapse rates and adverse effects of oral dexamethasone vs.
Studies including adult asthma patients and utilizing the parenteral route of administration of dexamethasone or prednisone were excluded. We also excluded non-randomized studies, retrospective studies, case-series, and non-English language studies.
The last literature search was conducted on 1st August After assessing the studies by their titles and abstracts, full-texts of selected articles were retrieved.
Both the reviewers assessed individual studies based on inclusion criteria. Disagreements, if any, were resolved by mutual agreement. Using an abstraction form, two reviewers retrieved data from selected studies. The primary outcome was the relapse rate defined by an unscheduled visit to the ED or clinic.
Secondary outcomes were hospital readmission after discharge and incidence of vomiting at ED or home. Every study was evaluated for the following variables: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases.
We rated studies on each variable as low risk, high risk, or unclear risk of bias. Anticipating heterogeneity amongst studies, a random-effects model was used to calculate the pooled effect size. Heterogeneity was calculated using the I 2 statistic. A sensitivity analysis was carried out to assess the influence of each study on the pooled effect size. Sub-group analysis was conducted for relapse rates based on follow-up period 1—5 days or 10—15 days and dosage of dexamethasone.
Using the method described by Muncer et al. Gpower software was used to calculate the power of studies. Out of the potentially relevant articles, 10 were selected for full-text analysis Figure 1. Three studies evaluated intramuscular dexamethasone vs. A total of seven unique articles were included in this systematic review and meta-analysis 171318 — Details of individual studies are presented in Table 1.
All trials included pediatric patients, however, the age group varied across studies. All studies were performed in the ED with varying sample sizes 23— patients. One study excluded patients with severe asthma exacerbation One included patients with moderate severity of exacerbation only 1 while another study included patients with moderate to severe exacerbations Asthma severity was measured on different scales across trials.
With an exception of one study 20there was no statistical significant difference between asthma severity scores of the two study groups. Dexamethasone was administered as a 1-day 11318 or 2-days therapy 720 In one trial, patients were randomized into three groups of 1-day dexamethasone, 2-days dexamethasone, and prednisone Data of both dexamethasone groups were compared separately with prednisone in our meta-analysis.
The dosage of dexamethasone in the included studies was 0. Majority studies had an institutional asthma management protocol wherein additional drugs were given to all patients of the trial. Inhaled or nebulized salbutamol, albuterol, and ipratropium bromide were commonly administered in the included studies. The follow-up period ranged from 1 to 15 days. For the meta-analysis, two sub-groups were created based on the follow-up period of relapse rates 1—5 days and 10—15 days.
There was no significant difference in the relapse rate between dexamethasone and prednisone at 1—5 days RR 1.
With an overall relapse rate of 8. Sub-group analysis was carried out for 1-day and 2-days dosage of dexamethasone vs.
Figure 2. Forrest plot for dexamethasone vs. Figure 3. Hospital readmission after initial discharge was evaluated by four trials 71318 With a re-admission rate of 1. Data on the incidence of vomiting in ED were retrieved from four studies 71318 Patients receiving dexamethasone vomited less frequently as compared to prednisone RR 0. The frequency of vomiting at home was significantly higher with prednisone 5. Figure 4. Figure 5.
There was no change in direction of effect size on sensitivity analysis for the variables: relapse rate, hospital readmission, and vomiting at home. However, when the results of Qureshi et al. Figure 7. For the outcome variables, relapse rate and hospital readmission rate, all studies were underpowered. The weighted mean effect size for relapse rate was 0. The power of our meta-analysis for detecting significant difference in relapse rate was For the variables, vomiting at ED and vomiting at home, the weighted mean effect sizes were 0.
The authors' judgment of the risk of bias is presented in Figure 8. Randomization was adequately described in five studies 1131820 An appropriate method of allocation concealment was utilized in four trials 11318 Only three studies 11820 provided sufficient information on blinding of participants and personnel while only two trials 118 reported blinding of outcome assessment.
Attrition bias was found to be high in two studies 19 Figure 8. Risk of Bias assessment. Green, low risk of bias; Yellow, unclear risk of bias; Red, high risk of bias.
Management of acute asthma exacerbations in children not only depends on the therapy provided in the ED but also on strict adherence to medications prescribed on discharge. On the other hand, Butler et al. Non-compliance to medications on discharge has been attributed to several factors like inadequate funds or lack of insurance, insufficient knowledge on the necessity of treatment, fear of side-effects and prolonged course of treatment 38 Dexamethasone, a long-acting corticosteroid, has been studied as an alternative to prednisone to allow a shorter course of treatment in asthmatic patients 4.
While inhaled and single-dose IM dexamethasone may be used as a substitute to prednisone, oral formulation is preferable in managing children 9 Studies conducted on adult asthmatic patients have found no difference in relapse rates with 2-days oral dexamethasone and 5-days prednisone 24 Rehrer et al.
In our study, while comparing the use of oral dexamethasone and prednisone in pediatric asthma exacerbations, we found no difference in relapse rates between a short-course of dexamethasone as compared to the standard 3—5 days therapy of prednisone. The hospital readmission rates after initial discharge were slightly higher with dexamethasone as compared to prednisone 1.
The results of our study are similar to the previous meta-analyses on this subject. Keeney et al. However, results from both IM and oral dexamethasone trials were pooled in their analysis.
Normansell et al.
Corticosteroids play an important role in the treatment of acute asthma exacerbations in the ED as well as post discharge from the ED. Further research is. Oral prednisolone is preferred if there is a history of severe asthma, life-threatening asthma, non-response to inhaled corticosteroids, or chronic use of high-. Prednisone is an oral steroid medication. If you have serious worsening of asthma symptoms (an asthma attack), your doctor may prescribe a brief. oral prednisolone for acute exacerbation of asthma. A randomized control trial. Banoth, Bhaskar; Verma, Anjali; Bhalla, Kapil; Khanna, Alok; Holla, Saraswathi;. Oral steroids, which have a potent anti‐inflammatory effect, are recommended for all but the most mild asthma exacerbations; they should be. Eur Respir J ; Treatment with OCS has demonstrable biological plausibility and is effective, although at higher doses, in the settings of steroid insensitivity. J Adv Nurs. Unsupervised phenotyping of Severe Asthma Research Program participants using expanded lung data. Reductions in airway hyper-responsiveness are seen over many months, 13 a much longer timeframe than that seen for inflammation.Severe asthma represents a significant burden of disease, particularly in high income nations; oral corticosteroids OCS remain an important part of the management toolkit for these patients. Resistance or insensitivity to corticosteroids is a feature of severe asthma, with persistent type 2 inflammation often occurring despite regular use of OCS. OCS remain the only accepted, effective treatment for acute asthma, and also continue to play an important role in the long term management of severe asthma, in spite of their significant side effect profile.
Even with the availability of the new biological therapies against IgE and interleukin-5, it is likely that a large proportion of patients will continue to require OCS to control their asthma. Future work should focus on optimising the balance between OCS efficacy and safety, and continued development of agents that allow reduction, or ideally discontinuation of their use, is needed. Asthma remains one of the most common chronic respiratory conditions worldwide, affecting about million people.
The prevalence is particularly high in most resource-rich nations, and is on the rise. However, OCS still remain critical in the maintenance of severe asthma and in the management of acute exacerbations. Before the s, the treatment for asthma was restricted to those compounds that were either plant-derived or adrenaline derivatives. This treatment consisted primarily of bronchodilator agents.
It was not until that the association between successful treatment with OCS and a reduction in eosinophils in the sputum was noted. The subsequent development of inhaled corticosteroids and the recognition that these can be equally as effective in the majority of patients with asthma, therefore, led to a decline in the use of OCS, except in the population with severe asthma.
The anti-inflammatory nature of OCS is the key to their efficacy in asthma. At present, it is suspected that at least half of all patients with asthma have predominantly eosinophilic inflammation, including the majority with early onset disease associated with allergy.
In these individuals, a complex interaction between genetics, airway damage and a maladaptive immune response within the airways leads to the development of asthma. The presence of this inflammation is associated with increased thickness of the smooth muscle layer, excessive and variable airway narrowing airway hyper-responsiveness and increased secretion of mucus.
Corticosteroids are effective at targeting numerous elements of this pathway. Eosinophils, especially, respond quite rapidly to corticosteroids and undergo apoptosis due to down-regulation of the roles of IL-5 and granulocyte-macrophage colony-stimulating factor in promoting eosinophil survival.
Reductions in airway hyper-responsiveness are seen over many months, 13 a much longer timeframe than that seen for inflammation.
Although corticosteroids reduce the thickness of the reticular basement membrane in asthma, their effect on the increased airway smooth muscle seen in asthma is not known. The pathology of severe asthma is similar in nature but more marked in terms of inflammatory cell infiltration and remodelling than that of milder asthma cases; however, an additional inherent feature of severe asthma seems to be a resistance, or at least insensitivity, to the effect of corticosteroids.
Interestingly, eosinophilia in treated severe asthma has not been linked with increases in cytokines from the type 2 inflammatory pathway, and these are found in lower concentrations than in steroid-naive patients with milder asthma.
These findings were recently replicated in the larger Severe Asthma Research Program SARP — a severe asthma cohort in which about half of the patients had persistent type 2 inflammation. At least one small study of children with difficult asthma showed that OCS resulted in a similar improvement in lung function irrespective of whether the children had elevated sputum eosinophils or not.
Thus, OCS remain a key therapeutic option for patients with severe asthma, particularly in the setting of active type 2 inflammation, due to their efficacy at multiple levels of the inflammatory cascade.
Treatment with OCS has demonstrable biological plausibility and is effective, although at higher doses, in the settings of steroid insensitivity. Current asthma guidelines recommend advancing asthma treatment in a step-wise fashion to reach disease control, for both improvement in symptoms and prevention of exacerbations.
Until recently, regular use of OCS was often the only effective option for those with severe disease that could not be controlled with the previous steps. Contemporary research has therefore focused on optimal dosing, and a Cochrane review has confirmed that OCS treatment that is titrated based on sputum eosinophil counts results in reductions in exacerbation rates compared with dosing based on clinical markers alone.
When used appropriately, these biological agents are effective at reducing exacerbations and improving symptoms and control. To date, even with the introduction of the new biological agents, there remains a prominent role for OCS in the management of severe asthma. In the setting of the anti-IgE agent omalizumab for severe allergic asthma, in one review omalizumab has not been shown to allow a dose reduction in OCS.
The remaining patients continued to use OCS, although at lower doses than at the onset of the study. Therefore, the experience, at least so far, with the biological agents has been that continued use of OCS is likely to remain important in a large proportion of patients with severe asthma, and even in the setting of these novel biological therapies, there is still a role for long term treatment with OCS as adjunctive therapy.
Further study is required to determine why this may be the case, but it may be due to the multiple pathways through which corticosteroids have an anti-inflammatory effect in asthma. Nevertheless, given the potential adverse effects with OCS, it is hoped that this role will be reduced in the presence of biological agents. Despite the long history of OCS use in severe asthma, there are no studies that have determined the optimal duration or dose to control the disease.
Although titrating OCS to target normalisation of biomarker values has shown promise in a pilot study, 32 the optimal way to use these markers will require more definitive evidence. The population with severe asthma is the last major cohort of patients with asthma who continue to be treated with long term maintenance OCS, and no discussion of the role of OCS would be complete without acknowledging the significant long term side effects of treatment which have been recognised since their early initial use in the s.
The most common serious complications include: bone density loss and risk of fracture, weight gain and metabolic syndrome, adrenal suppression and relative immunosuppression. In particular, the use of bisphosphonates to prevent osteoporosis is recommended, and gastric ulcer prophylaxis should be considered for those patients at risk.
The most well defined and frequent use of OCS in the management of severe asthma is during an asthma exacerbation. The current Global Initiative for Asthma guidelines suggest that an asthma exacerbation is a progressive increase in symptoms sufficient to require a change of treatment. In one study in patients with moderate to severe asthma, the frequency of eosinophilic exacerbations was reduced by OCS, whereas non-eosinophilic exacerbations, which were the most common type, were not reduced.
In summary, OCS continue to play an important role in the management of severe asthma. In spite of their well known and significant side effects, they remain a crucial element in the management of this disease.
Even with the availability of the novel biological therapies targeting IgE and IL-5, a large proportion of patients will continue to require OCS to control their asthma. This situation is unlikely to change in the near future. Further work should explore ways to optimise the balance between their efficacy and their safety. Provenance: Commissioned; externally peer reviewed. Publication of your online response is subject to the Medical Journal of Australia 's editorial discretion.
You will be notified by email within five working days should your response be accepted. Basic Search Advanced search search. Use the Advanced search for more specific terms. Title contains. Body contains. Date range from. Date range to. Article type. Author's surname. First page.
Issues by year. Article types. Research letters. Guidelines and statements. Narrative reviews. Ethics and law. Medical education. Volume Issue 2 Suppl. Appropriate use of oral corticosteroids for severe asthma. Med J Aust ; 2 : SS Topics Respiratory tract diseases.
Endocrine system diseases. Immune system diseases. Summary Severe asthma represents a significant burden of disease, particularly in high income nations; oral corticosteroids OCS remain an important part of the management toolkit for these patients. History of oral corticosteroids use in asthma Before the s, the treatment for asthma was restricted to those compounds that were either plant-derived or adrenaline derivatives.
Oral corticosteroids in the management of acute exacerbation of asthma The most well defined and frequent use of OCS in the management of severe asthma is during an asthma exacerbation. Conclusion In summary, OCS continue to play an important role in the management of severe asthma. View this article on Wiley Online Library. Uncontrolled asthma: a review of the prevalence, disease burden and options for treatment.
Respir Med ; Eur Respir J ; Economic burden of asthma: a systematic review. BMC Pulm Med ; 9: After asthma: redefining airways diseases. Lancet ; McCombs RP. Serial courses of corticotrophin or cortisone in chronic bronchial asthma. N Engl J Med ; Brown HM. Treatment of chronic asthma with prednisolone; significance of eosinophils in the sputum. Lancet ; 2: Summing up years of asthma. Evolving concepts of asthma. The interaction between mother and fetus and the development of allergic asthma.
Expert Rev Respir Med ; 8: Israel E, Reddel HK. Severe and difficult-to-treat asthma in adults. Wenzel SE.
Comments
Post a Comment