Reducing Oral Corticosteroid Dependence in Severe Asthma by Balancing Benefits, Burdens, Path to Safer Care

Reducing the use of oral corticosteroids in patients with severe asthma is a pressing concern due to their associated adverse effects, health care costs, and impact on quality of life. | Image Credit: rashyn- stock.adobe.com

Despite their critical role in managing severe asthma for more than 70 years, oral corticosteroids are associated with significant adverse effects (AEs) and increased health care costs, highlighting an urgent need for clear tapering guidelines and collaborative patient-provider strategies, according to a study published in Allergy.¹

Asthma medication costs have been a persistent barrier to effective management.² Although a June 2024 announcement by 3 major inhaler manufacturers capping out-of-pocket costs at $35 monthly for commercially or privately insured and uninsured individuals is a step toward accessibility, it excludes those with public insurance and doesn't eliminate affordability issues for all.

Researchers reviewed the benefits and burdens of oral corticosteroids in severe asthma, from both patient and provider perspectives, to identify strategies for reducing oral corticosteroids reliance.¹

Systemic corticosteroids administered in the emergency department (ED) for acute asthma exacerbations demonstrate reduced hospitalization risk, particularly in severe cases and for patients not already on oral corticosteroids. Oral corticosteroids also significantly prevent asthma worsening within 7 to 10 days post exacerbation (risk ratio [RR], 0.38; 95% CI 0.20-0.74) and offer a cost-effective treatment. Patients themselves recognize oral corticosteroids as an effective "safety net" for severe asthma, often describing them as "keeping them breathing" despite being a "necessary evil."

The frequent short courses and long-term use of oral corticosteroids create substantial burdens for patients and health care systems. Historically, oral corticosteroids was the only option for asthma exacerbations, but new asthma therapies now exist. By optimizing maintenance treatment, clinicians can reduce the risk of severe exacerbations and, consequently, the need for emergency oral corticosteroids use.

Oral corticosteroids carry well established, AEs that affect the whole body, causing patient distress and impacting quality of life, especially when asthma control prevents tapering. Concerns include fear of both short- and long-term AEs and diminishing oral corticosteroids effectiveness. Cumulative oral corticosteroids doses, even as low as 500 mg, significantly increase the risk of serious AEs over time, a risk heightened by high inhaled corticosteroid doses, contributing to overall corticosteroid burden.

Long-term oral corticosteroids use is linked to numerous often irreversible comorbidities that worsen patient outcomes and may increase all-cause mortality. Abrupt oral corticosteroids cessation risks adrenal insufficiency and life-threatening adrenal crisis, common yet under recognized in oral corticosteroids-dependent patients with severe asthma. This risk adds to patient burden and reluctance to discontinue, underscoring the critical need for adrenal function monitoring to ensure safe oral corticosteroids withdrawal and prevent unacknowledged adrenal insufficiency.

Patients with severe asthma using maintenance or short-course oral corticosteroids demonstrate greater health care resource utilization, including increased hospitalizations and ED visits, compared with non-users. The review included a UK study that found oral corticosteroids users had an approximately 25% higher mean annualized rate of general practitioner visits, plus elevated risks for hospitalizations (RR, 1.14) and ED visits (RR, 1.26).

Higher daily oral corticosteroids doses (≥ 7.5 mg/day) correlated with a substantial 2.3 to 3-fold increase in health care utilization. A US claims data analysis further revealed that these increases were more frequently linked to oral corticosteroids-related AEs than to asthma symptoms, with high oral corticosteroids users experiencing more general practice visits and hospitalizations due to AEs.

Oral corticosteroids used regularly by patients with asthma notably increase health care costs, impacting both direct medical expenses and potentially indirect costs like absenteeism. An Italian registry found oral corticosteroids-related AEs in severe asthma cost €242.7 million annually. Swedish and US studies estimated annual health care costs for typical oral corticosteroids users to be 3 times greater, or an additional $2712 to $8560, respectively, largely due to oral corticosteroids-related complications.

A UK study corroborated this, showing 42% higher annual costs for patients with severe asthma on intermittent or long-term oral corticosteroids. Although data are scarce, oral corticosteroids use may also increase indirect costs, with a German study noting oral corticosteroids maintenance therapy led to approximately 1 week more sick leave and higher insurance payouts for sickness.

Achieving clinical asthma remission, defined by the absence of systemic corticosteroid need for at least 12 months, may be more challenging for patients on long-term oral corticosteroids, even those receiving biologics. This difficulty likely reflects more severe underlying disease in oral corticosteroids-dependent patients, as exacerbation frequency negatively correlates with remission likelihood.

Although maintenance oral corticosteroid users are often deemed dependent, this excludes patients with steroid-resistant asthma for whom oral corticosteroid is ineffective. Other definitions include patients with a clinical response to maintenance oral corticosteroid or those needing frequent rescue courses. However, many in the latter group may not be truly oral corticosteroid-dependent, as improved adherence and lifestyle adjustments could potentially control their asthma without oral corticosteroid.

Increasing inhaled corticosteroid doses to reduce oral corticosteroid use in asthma shows limited clinical benefit. Additionally, higher inhaled corticosteroid doses don't consistently prevent exacerbations and can increase AEs. Therefore, type 2 biomarker measurement is crucial to identify patients who truly benefit from increased inhaled corticosteroid. Although add-on azithromycin can reduce exacerbations, its oral corticosteroid-sparing effect is minimal, and long-term use risks antibiotic resistance. Even frequent short courses of oral corticosteroid, regardless of asthma severity, increase complication risks. This highlights the need to control underlying symptoms, optimize treatment adherence, and use tools like the Glucocorticoid Toxicity Index to minimize oral corticosteroid use and its associated adverse outcomes.

Biologics offer a significant advancement in treating severe asthma, especially for the 70% to 82% of patients with type 2 inflammation. Since omalizumab's approval more than 2 decades ago, several biologics targeting various inflammatory pathways have emerged. Used when standard therapies fail, these treatments reduce oral corticosteroid use, decrease asthma exacerbations by up to 72.9%, and can lower health care costs by reducing hospitalizations. Biologics are particularly beneficial for patients with coexisting type 2 inflammatory conditions like allergic rhinitis or chronic rhinosinusitis with nasal polyps, as they address multiple conditions and reduce the need for oral corticosteroids.

Real-world evidence and clinical trials confirm that biologics significantly reduce oral corticosteroiddependence in asthma patients. Omalizumab and IL-5/IL-5 receptor biologics (reslizumab, benralizumab, mepolizumab) have shown substantial oral corticosteroid dose reductions and even complete elimination for many. Notably, dupilumab is the only FDA approved biologic for oral corticosteroid–dependent severe asthma, demonstrating a 70.1% reduction in oral corticosteroid use and enabling nearly half of patients to discontinue oral corticosteroid entirely. Although tezepelumab's oral corticosteroid-sparing effects are less consistent, further research is ongoing.

Health care system challenges include a lack of centralized oral corticosteroid monitoring, leading to patients receiving multiple prescriptions and exceeding safe dosages. Limited access to and high costs of biologics, particularly in lower-income countries, also push reliance on cheaper oral corticosteroids. Many prescribers are unaware of oral corticosteroid stewardship guidelines or are hesitant to alter effective oral corticosteroid regimens. Furthermore, delayed or absent referrals to specialist asthma services prevent patients from accessing advanced management strategies.

Patient-related barriers include anxiety about symptom return or AEs from new treatments if oral corticosteroids are reduced. Patients may also over-rely on oral corticosteroids due to their perceived effectiveness, sometimes obtaining them without a valid prescription, highlighting a need for better education and alternative treatment options. Overall, oral corticosteroids are often used to manage co-existing conditions, making dose reduction more complex.

“Biologics are a potentially important tool for reducing OCS dependence in eligible patients, but guidance on best practices for tapering OCS is needed,” study authors concluded.

References

1. Canonica GW, Porsbjerg C, Price DB, et al. Burden of oral corticosteroid use in severe asthma: challenges and opportunities. Allergy. Published online June 23, 2025. doi:10.1111/all.16569
2. Santoro C. National Asthma and Allergy Awareness Month: economic costs, threats to access, and the impact of policy changes. AJMC^®. May 2, 2025. Accessed June 24, 2025. https://www.ajmc.com/view/national-asthma-and-allergy-awareness-month-economic-costs-threats-to-access-and-the-impact-of-policy-changes