One-third of patients with severe asthma found to be taking harmful doses of oral steroids

A third of patients with severe asthma are taking harmful doses of oral steroids, according to a study of several thousand people in The Netherlands, presented at the 2019 ERS International Congress.

The majority of these patients could avoid taking oral steroids by improving their adherence to their other asthma medication and their inhaler technique, Dr Katrien Eger told the Congress. However, there remains a proportion who might be eligible for treatment with new biologic asthma drugs, yet only half are receiving them.

Dr Eger (MD), a PhD student and pulmonologist in training at Amsterdam University Medical Centre (The Netherlands), told the congress: “Asthma patients using high doses of oral steroids are at risk of serious adverse effects such as diabetes, osteoporosis and adrenal insufficiency… Our findings show that many patients with severe asthma are taking harmfully high doses of oral steroids. Every prescription for oral steroids should alert doctors to assess adherence to inhaled therapies and inhalation techniques in these patients. Furthermore, now that there is an increasing number of biologic asthma drugs available that avoid the need for oral steroids, doctors should initiate biologic treatment in suitable patients to reduce exposure to harmful oral steroids.”

Dr Eger and her colleagues analysed information from a pharmacy database of 500,500 Dutch inhabitants to identify patients who were using high doses of inhaled corticosteroids (500 micrograms or more a day) plus long-acting beta agonists and who were identified as having severe asthma according to the Global Initiative for Asthma (GINA). The database also contained information on oral steroid use (cortisone). The researchers sent questionnaires to 5,002 of these patients and then analysed the 2,312 that were returned. Information from the pharmacy database enabled them to collect information on oral steroid use and adherence to medication. Pharmacists assessed inhaler technique in a sample of the patients.

“We found that 29 per cent of asthma patients who were using high doses of inhaled steroids were also taking harmfully high doses of oral steroids of 420 milligrams a year or more,” said Dr Eger. Of these patients, 78 per cent had poor adherence to inhaled medication or incorrect inhalation technique. So these problems should be tackled first in these patients before considering biologic treatment. The remaining 22 per cent are candidates for biologic drugs.

“If we extrapolate our results from the database to the general Dutch population, this would mean that there are about 6,000 patients with severe asthma who are candidates for biologic treatment – 1.5 per cent of the whole asthma patient population. But less than half – 46 per cent – are currently receiving it. This shows that there is potential to substantially reduce oral steroid overuse.”

Although biologic treatments, such as omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab, are more expensive, identifying and treating patients who could benefit from them would have economic benefits, said Dr Eger.

“If they reduce exposure to harmful oral steroids and thus reduce the adverse effects, this could lead to a reduction in the cost of healthcare. Another important way to look at this, is that patients can exercise more and experience fewer exacerbations of their disease, and so have fewer days off work due to illness.”

The proportion of asthma patients who do not adhere to their inhaler medication or have poor inhaler technique is likely to be similar in other countries. However, access to biologic treatment may vary between countries.