Asthma

Consensus on tapering to curb excessive use of oral corticosteroids


An international consensus statement on tapering oral corticosteroids (OCS) in asthma may be an important step in reducing excessive exposure in the absence of clear guidance, experts say.

After a study process involving 131 experts from around the world, it was agreed that OCS tapering should be attempted in all patients with asthma receiving maintenance oral corticosteroid therapy, with the “rhythm and speed” of tapering attempts personalised to the individual.

Almost all (95%) of the experts consulted by the Oral Corticosteroids Tapering Delphi Expert Panel agreed that in general the goal should be not to use oral corticosteroids and to minimise dose and duration of treatment.

Short-term OCS is appropriate in patients experiencing acute non-resolving or life-threatening exacerbations as well as those with eosinophilic or allergic exacerbations and within an asthma management plan or to avoid hospitalisation, the experts concluded.

Maintenance OCS use was considered by those taking part to be appropriate in patients with severe asthma who had inadequate control despite being on GINA step 5 treatments.

Writing in the American Journal of Respiratory and Critical Care Medicine, the French, British, Italian and American panel said a cumulative yearly dose of 0.5 or 1g prednisolone equivalents would be indicative of poor asthma control.

But when it came to the specifics of how to wean a patient off OCS there was less agreement – including over the speed of OCS tapering in patients with a fast or slow response, and whether tapering should be guided by biomarkers.

Biologics should play an important role in OCS tapering  the experts agreed, and failure to achieve 50% OCS dose reduction or greater suggests a switch is needed.

Yet no consensus could be reached on the assessment and management of adrenal insufficiency, suggesting a need for more research.

“To our knowledge, no existing asthma-specific guidelines are currently available to guide OCS tapering in clinical practice,” the consensus authors said, adding that the consensus could be used to inform clinical practice of patients with severe asthma.

“The recommendations also provide a first step towards development of an OCS tapering algorithm and support the ongoing OCS stewardship effort by international respiratory experts to reduce the harm from inappropriate OCS use and its consequences.”

Dr David Jackson, Consultant Respiratory Physician and Clinical Lead for Asthma Care at Guy’s & St Thomas’ NHS Trust said the expert consensus marked an important step forward in reducing the “the often excessive OCS exposure many of our patients endure”.

But he said there remained much work to do in reducing the significant variation in current practise and opinion, which was highlighted by the study.

“Indeed the fact that a third of respondents either agreed or were neutral in their response to the statement that ‘maintenance OCS therapy is appropriate in severe asthmatics with low-T2 phenotypes’ is surprising given the paucity of data supporting benefit of steroids in the absence of T2 inflammation and even more troubling given the significant harm to patients in receiving maintenance steroids,” he said.

Dr Jackson added the recently published results for the steroid-sparing PONENTE study also provided a helpful protocol for effective but safe OCS weaning.

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