Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand

John Blakey, Li Ping Chung, Vanessa M McDonald, Laurence Ruane, John Gornall, Chris Barton, Sinthia Bosnic-Anticevich, John Harrington, Mark Hew, Anne E Holland, Trudy Hopkins, Lata Jayaram, Helen Reddel, John W Upham, Peter G Gibson, Philip Bardin, John Blakey, Li Ping Chung, Vanessa M McDonald, Laurence Ruane, John Gornall, Chris Barton, Sinthia Bosnic-Anticevich, John Harrington, Mark Hew, Anne E Holland, Trudy Hopkins, Lata Jayaram, Helen Reddel, John W Upham, Peter G Gibson, Philip Bardin

Abstract

Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk-benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.

Keywords: corticosteroids; position paper; severe asthma; side effects; stewardship.

Conflict of interest statement

John Blakey has received a contract from Astra Zeneca (AZ) to deliver research (phase 2 RCT), grant funding from Novartis for an investigator‐initiated study and a contract from GSK to deliver research (multicentre phase 3 RCT); consulting fees from GSK, Chiesi and Boehringer Ingelheim (BI); honoraria for speaking at educational meetings, podcasts and vodcasts from AZ, GSK and Chiesi; travel support to attending meetings from GSK, BI and AZ; medical writing support from GSK and Teva; payment for advisory work from Asthma Australia; and has served on the advisory board of Asthma WA and the steering committee of Optimum Patient Care Australia. Li Ping Chung has received consulting fees from GSK, AZ and Chiesi for advisory board meetings over the past 5 years on topics related to asthma; and honoraria from GSK, AZ, BI, Novartis and Chiesi for speaking/organizing educational events. Vanessa M. McDonald has received honoraria from AZ for lectures at the TSANZ and the APSR meetings on OCS use in severe asthma. Sinthia Bosnic‐Anticevich has received research grants from Teva, GSK and Mylan in the area of inhaler device use, severe asthma, primary care management of asthma and chronic obstructive pulmonary disease and managing allergic rhinitis in the community pharmacy; consulting fees from Teva, Sanofi, Mylan and GSK for the development of educational materials for GPs and pharmacists; honoraria from Teva, Sanofi, Mylan, GSK, AZ and BI for lectures on medicines use, inhaler devices, patient perspectives to respiratory medicines use and allergic rhinitis management; and has participated on advisory boards of Teva, AZ and BI related to inhaler devices. She is President of the Respiratory Effectiveness Group, Chair of Allergic Rhinitis in Asthma (ARIA) in Pharmacy and Chair of the TSANZ's Primary Care Special Interest group. Mark Hew has received grants and consulting fees from Sanofi, GSK, AZ and Novartis paid to his institution; and honoraria for presentations from Teva, Sanofi, GSK and AZ paid to his institution. Anne E. Holland has received fees and travel support from AZ for a non‐promotional speaking engagement (unrelated to the present work). Helen Reddel has received research grants from AZ for investigator‐sponsored research; research grants GSK and Novartis for investigator‐sponsored research and registries; and honoraria from AZ, GSK, Teva, BI, Sanofi and Chiesi for independent medical education. She's been on advisory boards of AZ, GSK, Novartis, Chiesi and Sanofi; is Chair of GINA Scientific Committee; and a member of the Australian Asthma Guidelines Committee for the National Asthma Council. John W. Upham has received speaker fees from AZ, GSK and Sanofi and served on advisory boards of AZ, GSK and Sanofi. He was the TSANZ President in 2021–2022. Peter G. Gibson received grants from GSK and NHMRC paid to his institution; honoraria from GSK, Novartis and AZ for lectures/presentations; and advisory board payments from Sanofi and Chiesi. Philip Bardin has received honoraria from GSK, Novartis, Sanofi, BI and AZ for lectures/presentations, and from GSK, AZ, Novartis and Sanofi for participation on an Advisory Board, donated to the Departmental Research Institute. Laurence Ruane, John Gornall, Chris Barton, John Harrington, Trudy Hopkins and Lata Jayaram have nothing to disclose.

© 2021 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.

Figures

FIGURE 1
FIGURE 1
For every 10 people with acute asthma, two will improve with bronchodilators alone, six will improve if they were also given oral corticosteroids and two will fail to improve. Outcomes at day 4, data from the 1956 MRC trial. This historic study predated introduction of inhaled corticosteroids
FIGURE 2
FIGURE 2
Stepwise multidimensional assessment of individuals who are potentially being considered for treatment with oral corticosteroid. Content has been reproduced with permission from the Centre of Excellence in Severe Asthma, originally developed as part of the Centre of Research Excellence in Severe Asthma (https://toolkit.severeasthma.org.au)
FIGURE 3
FIGURE 3
Depiction of inhaled or oral glucocorticoid efficacy and responsiveness in the treatment of asthma. In mild asthma, benefit can be achieved at low doses, efficacy is reduced in moderate severity disease whereas in patients with corticosteroid insensitivity limited benefit is gained, even at high doses
FIGURE 4
FIGURE 4
Harmful effects of oral corticosteroids in asthma are common and widespread and affect all organ systems. VTE, venous thrombo‐embolism
FIGURE 5
FIGURE 5
Natural frequency diagram highlighting the prevalence of high cumulative dose oral corticosteroid exposure in asthma. Based on data from studies by Hew et al.
FIGURE 6
FIGURE 6
Proportion of people with asthma who reported experiencing specific symptoms attributable to oral corticosteroid side effects and the median proportion of patients estimated by clinicians to experience these side effects. Redrawn from Cooper et al.

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