OCS in severe asthma care:
Time to end over-reliance

Having previously run one of the largest severe asthma clinics in the UK, I’m all too familiar with the complicated relationship many people with severe asthma have with systemic corticosteroids (SCS), including oral corticosteroids (OCS).

Despite the introduction of updated treatment strategies and novel therapies for asthma, OCS use still remains high. Although OCS are an effective treatment for acute asthma attacks and improving symptom control, the increased risk of acute and chronic adverse effects from frequent acute OCS prescriptions is often underestimated.^1-4 As a consequence, it is vital that we continue to encourage responsible prescribing habits with an aim to minimise chronic and cumulative OCS exposure whenever possible. Invariably, when patients would first come to see me their number one concern was their OCS use, and their number one question was – “How can I get off these medicines?”

The time has come to fundamentally change the role of OCS in severe asthma care.

Oral corticosteroids in the treatment of severe asthma

Severe asthma is a heterogenous and complex disease, with multiple underlying drivers.^5,6 26 million people were estimated to have been affected worldwide in 2019,^1,7 experiencing frequent exacerbations and significant limitations on their lung function and quality of life.^1-4

For over 60 years we have relied on OCS as a mainstay of severe asthma treatment to help people manage their exacerbations.⁸ More than 13.5 million people worldwide with severe asthma currently rely on OCS to control exacerbations and prevent hospitalisations.^1-3,7,9 This cumulative, long-term use of OCS is associated with debilitating side effects for patients and can place further burden on their quality of life.^2,3,10 Chronic OCS use carries the potential for serious health risks, including diabetes, osteoporosis and heart disease.^4,11,12 In fact, potential OCS-induced morbidities have been identified in 93 percent of people with severe asthma ¹¹, with recent studies indicating that long-term use is associated with a higher risk of mortality compared with non-use ¹³.

OCS reduction in other disease areas gives us hope to replicate this success in severe asthma

In other disease areas we have seen a recent decline in the use of OCS, for example rheumatology, in which OCS were once the commonplace standard of care.^8,14 For decades, steroids were used to help control symptoms for people with rheumatoid arthritis. ^8,14 Now with earlier diagnosis, alongside the advent of novel treatments, rheumatologists have been able to revolutionise patient care and substantially reduce OCS use. ^8,14

We must embrace learnings from other disease areas like rheumatology where clinicians have found success in reducing OCS use.^8,14 When coupled with clear evidence on how to safely, effectively achieve this in severe asthma, we have the potential to dramatically change patient outcomes for the better. OCS tapering is fundamental to reducing short and long-term adverse effects.

Embracing evidence that suggests guideline changes are key progress drivers

A growing body of evidence, including examples from other chronic diseases, is emerging that could further inform guidelines to drive greater adoption of OCS-sparing strategies and enable physicians to safely and effectively taper their patients from OCS.¹⁵

The medical community must embrace this emerging evidence and put it into practice as quickly and responsibly as possible. With recent scientific advancements and targeted therapies now an option for many patients who were previously reliant on OCS, alongside evidence supporting safe OCS-sparing strategies, I’m incredibly hopeful that we can achieve an improved approach to severe asthma treatment.

A concerted effort to implement change

Although global guidelines for severe asthma are being put in place, multiple barriers against change still exist and recommendations need to be adapted on a country-by-country basis. A comprehensive and concerted effort is necessary to tackle the issues of reliance on OCS which is why it will be crucial to change national and local policies alike. The recently published World Allergy Organization Journal article on Systemic Corticosteroids in Asthma therefore calls on the global respiratory community to work alongside clinical leaders, patient advocates and healthcare systems to transform standards of care and truly relegate OCS use to a last resort. Specific steps, including defining a threshold for OCS use and raising awareness of appropriate usage, have been identified as a goal that the community can work towards, to ensure patients with severe asthma routinely receive timely care, in the most appropriate setting. 

Additionally, an OCS Charter to Fundamentally Change the Role of Oral Corticosteroids in the Management of Asthma was published to reframe the relationship that patients living with asthma and their healthcare team have with OCS. Shifting mindsets and implementing the latest guidelines could bring clinical practice closer to other disease areas who have had success, and ultimately, make a significant impact in the long-term health of people living with severe asthma.